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05/18/2018

The Current State of Nursing Care: A Conversation with Dr. Barbara Ihrke (May 16th)

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Nurses, today numbering over four million, represent the largest segment of the healthcare workforce and deliver the majority of direct patient care.   Their role in determining care quality (and safety) cannot be under-estimated.  Absent adequate nursing care patients can face a long list of nonfatal and fatal outcomes.  The profession however suffers a number of challenges due in part to both an aging population and one that is increasingly co-morbid.  For example, not only are hospital patients more sick (i.e., have higher acuity) but because of financial pressures their lengths of stay have decreased.  Among other issues facing the profession are the increasing demand for nurses (there's presently a nurse shortage that is only expected to grow worse), the increasing demand for higher educational attainment, increasing administrative burdens (that takes away from their ability to provide direct care), an aging nurse population, career burnout, long standing/persisting scope of practice issues that limits their ability to "practice to the top of their licence" and the lack of nurses in organizational leadership positions. 

During this 27 minute conversation Dr. Ihrke discusses nursing education, the nurse shortage, nurse job satisfaction, scopes of practice issues and the under-representation of nurses on hospital and related health care institution boards.   

Dr. Barbara Ihrke is currently Vice-President for Academic Affairs, School of Nursing, at  Indiana Wesleyan University.  She Ihrkehas been on faculty at Indiana Wesleyan University (IWU) since 1994 as Professor, Division Chair, and Executive Director before serving as Dean of the School of Nursing in 2010.  Dr. Ihrke's research focus includes trans-cultural experience and spiritual care.  Her writings have also covered nursing education, clinical informatics and nurse leadership.  Dr. Ihrke overseas work includes serving on an IWU research team that studied Zika on the Island of Gonave, Haiti.   Dr. Ihrke received her doctorate from Purdue, her Masters in community health nursing from IWU and her undergraduate in nursing from St. Cloud School of Nursing.  She earned another under graduate degree in Missions from Crown College and a certificate in Tropical Medicine. 

Cited during  this interview are research findings, in part, by the National Academies of Science, see, for example, "The Future of Nursing: Focus on Education (2011): http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/Report-Brief-Education.aspx. 

05/09/2018

Dr. Tim Williams Discusses the Use of Patient Reported Outcome Measures (PROMs) in the United Kingdom: May 8th

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Healthcare payment models have been increasingly evolving to include quality performance in determining reimbursement.  For example, the Medicare program, including Medicare Advantage, is today littered with quality performance measurement.  Measuring quality in healthcare is, however, not as simple or straight forward as frequently assumed.   Among other challenges, measures developed to date overwhelming measure healthcare process, not outcomes.  Providers typically report on measure sets unique to each payer causing them undue collection and reporting burden, which measure is attributed to which provider can be or is an inexact and under pay for performance agreements comparatively higher quality scores does not always translate to comparatively greater financial reward.  Because of these problems and related others, Patient Reported Outcome Measures (or PROMs) are increasingly seen as a solution.  They reduce provider reporting burden, they are largely outcome based, are more responsive to patient care goals, help to better engage or activate the patient, PROMs data can be, or is, reported real time and can enable more efficient and more timely care delivery.

During this 27 minute conversation Dr. Tim Williams discusses how/why My Clinical Outcomes was formed, how PROMs measures are used in the clinical practice setting and for primarily what disease conditions, what opportunities or advantages they present to improve care delivery and outcomes, the extent to which they've been adopted in the UK, and what might American payers and providers learn from My Clinical Outcomes' PROMs experience.     

Dr. Tim Williams is currently CEO (and cofounder) of My Clinical Outcomes a London-based, an IT company that automates for Williams health care providers, via a web-based platform, the collection and analysis of Patient Reported Outcome Measures (PROMs).  He founded My Clinical Outcomes in 2011 to help bridge the gap in patient-centered care data available to inform clinical care.  Previously, Dr. Williams worked as a physician for the UK's National Health Service and as a healthcare management consulting also for the NHS.   

For more information on My Clinical Outcomes go to: http://www.myclinicaloutcomes.com/

See also this recent April 19 essay by Dr. Williams and myself in The Health Care Blog, "Patient Reported Outcome Measures: Progress Across the Pond," at: http://thehealthcareblog.com/blog/2018/04/19/patient-reported-outcome-measures-progress-across-the-pond/

05/08/2018

Clarification: Per My April 17th Interview with Kip Sullivan, Is the ACO Program Reducing Medicare Spending?

Per my April 17th conversation with Kip Sullivan concerning the Medicare Shared Savings Program/MSSP (ACOs), I noted an August 2017 OMB report that concluded the MSSP saved a net $1 billion in its first three years, i.e., gross savings, OMB reported, equaled $3.4 billion, losses (or reimbursements above benchmarks) equaled $2.4 billion, for a net savings of $1 billion.   OMB also reported, however, CMS paid out $1.3 billion in earned shared savings thereby implying the program lost $300 million. 

I've disputed whether the MSSP actually lost $2.4 billion for several reasons including moreover there's no comparison group and we cannot know what these providers would have spent, the counterfactual, had they not participated in the ACO program.

In back and forth with Mr. Sullivan subsequent to our discussion, he has made the very valid point that if we cannot know if the program lost money we cannot equally know if it produced Medicare savings.     

04/27/2018

"The Never-Ending Misuse of Antipsychotics in Nursing Homes" (April 27th)

If you missed my February 15th interview with Human Rights Watch's Ms. Hannah Flamm regarding her report, "They Want Docile," How Nursing Homes in the US Overmedicate People With Dementia," my related essay under this title is posted on the Health Affairs Blog.  It's at: https://www.healthaffairs.org/do/10.1377/hblog20180424.962541/full/.  

04/18/2018

Kip Sullivan Discusses the Flaws and Future of the Medicare ACO Program (April 17th)

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The Medicare Shared Savings Program's Accountable Care Organization (ACOs), created by Section 3022 of the 2010 Affordable Care Act constitutes the flagship Medicare pay for performance (P4P) program.  Though there are other P4P (also termed pay for value) models, for example two bundled payment models (Bundled Payments for Care Improvement and Comprehensive Care for Joint Replacement), they are short-lived CMS demonstrations.   If the federal government is to bend the Medicare spending curve or make the program more financially sustainable it will likely be due moreover to the success of ACOs.  Though provider participation in ACOs is substantial, this year there are 561 ACOs providing care to 10.5 million Medicare beneficiaries, the program has to date achieved marginal success.  Over four performance years (2013-2016), ACOs have saved substantially less than one percent of annual Medicare spending (now over $700 billion) - which is why the DHHS Secretary Alex Azar recently admitted candidly ACO performance has been "underwhelming" and "lackluster."  Even before the Medicare ACO program formally began there have been questions and criticism about the model's design.  Perhaps no one has written more about the model's flaws than Kip Sullivan.    

During this 32 minute conversation Mr. Sullivan discusses the genesis of ACOs including results from its predecessor, the Physician Group Practice demonstration, assumptions made in the the design of the model, e.g., the relationship between cost and quality and the effectiveness of financially incenting physicians, and moreover the problem of addressing care quantity instead of pricing.  In sum, Mr. Sullivan argues the Medicare ACO model is fatally flawed and will not achieve meaningful success. 

Mr. Kip Sullivan is currently a member of the board of the Minnesota chapter of Physicians for a National Health Program.  Mr. Sullivan began his career as a staff attorney for the New York Legal Aid Society and as a researcher for Citizens Action SullivanLeague in California.  Form 1980 through 2000 he researched universal health insurance and a single payer system for Minnesota COACT (Citizens Organized Acting Together).   He also served as a consumer representative on the Minnesota Governor's Health Plan Regulatory Reform Commission in the 1980s.  From 2000 to 2007 Mr. Sullivan was a health system analyst for the Minnesota Universal Health Care Coalition.  Mr. Sullivan has written over 150 health policy articles for the American Journal of Public Health, the Journal of Health Politics, Policy and Law, the LA Times, The Nation, The New England Journal of Medicine, The New York Times, and others.  He published 2006 "The Health Care Mess: How We Got Into It and How We'll Get Out of It."  Mr. Sullivan earned his undergraduate degree from Pomona College and his law degree the Harvard School of Law.   

Mr. Sullivan's latest essay, "Curb Your Enthusiasm," is at: http://thehealthcareblog.com/blog/2018/04/16/curb-your-enthusiasm/.

The Lawton Burns and Mark Pauly essay titled, "Transformation of the Health Care Industry: Curb Your Enthusiasm," in the the recent Milbank Quarterly, that is noted during this discussion is at: https://onlinelibrary.wiley.com/doi/full/10.1111/1468-0009.12312.

04/13/2018

Pediatrician Dr. Niran Al-Agba Discusses Gun Violence (Via In Part Her Columbine Experience) (April 12th)

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Including the February 14th shooting at Marjory Stoneman HS in Parkland Florida that killed seventeen students and teachers, there have now been over 130 shootings in elementary, middle and high schools in 43 states since 2000 and another 58 shootings in US colleges and universities.  Gun violence in this country is in a word, obscene.  It is, for example, 96 times higher than in Japan and 55 times higher in the UK.  It is largely explained by gun prevalence.  The US accounts for approximately five percent of the worldwide population, however, Americans own 42 percent of the world's guns.   What also explains gun violence is a federal policy that has persisted since 1996, the so called Dickey amendment, that prohibited federal funding to conduct gun violence research.   (Since 1996 there have been approximately 600,000 gunshot victims.)  The recently passed omnibus spending bill (that funds the federal government through this fiscal year) included accompanying report language stating the Dickey Amendment does not prevent federal agencies, moreover the CDC, from conducting gun violence research.  However, the spending bill included no money to conduct gun violence research.   

During this 28 minute conversation Dr. Al-Agba discusses her experience treating survivors of the 1999 Columbine High School shooting (that killed 13 and wounded 21), why the physician community has been hesitant to discuss gun safety with their patients and what can be done by the physician community to reduce gun violence, e.g., participating in student threat assessments.   

Dr. Niran Al-Agba is an a board certified pediatrician in private practice in Silverdale, Washington and is affiliated with Al-Agbamultiple hospital in the region including Harrison Medical Center and MultiCare Mary Bridge Children's Hospital and Health Center.  She is a her family's third generation physician practicing in the Kitsap County.  She is also an Assistant Professor on at the University of Washington School of Medicine and is a lead instructor at Seattle Children's Hospital for the past 15 years.  She has been voted the Best Doctor in Central Kitsap for three of the last six years.  She is the independent practice editor for the Health Care Bog, published on KevinMD and RebelMD, and pens a monthly column for her local newspaper, The Kitsap Sun.  Dr. Al-Abga received her medical degree from the University of Washington School of Medicine, did her residency at the University of Colorado School of Medicine/Denver Children's Hospital.  

Dr. Al-Abga's March 10th essay titled, "I Treated the Columbine Kids, I Have Not Spoken Before," noted during this discussion is at: http://thehealthcareblog.com/blog/2018/03/10/i-treated-the-columbine-kids-i-have-not-spoken-out-before/.

 

03/27/2018

The Reverend Patricia Lyons Discusses the Administration's Proposed Protection of Religious Beliefs and Moral Convictions Rule: March 26th

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In January the Trump administration published a proposed DHHS rule titled, "Protecting Statutory Conscience Rights in Health Care, Delegations of Authority."  For decades the federal government, via several legislative amendments, has protected healthcare providers who object to performing, or object to assist in performing, certain medical procedures based on their freedom of conscience and religious exercise.  While these protections moreover concern abortion they have been gradually expanded to include, for example, refusal to participate in assisted suicide.  The proposed rule however vastly expands these protections.  The administration is proposing a regulatory rule that would allow all health care personnel (as well as hospitals, labs, insurance companies and others) to refuse to provide any medical care to any person by claiming conscience, moral or religious objection.  For example, a pediatrician could refuse to treat a child of gay parents or an emergency room nurse could deny providing a terminal patient end of life pain management.  The proposed would also allow the health care worker to refuse to refer a patient or identify anyone or organization that in turn could refer.  Critics of the proposed say the rule would effectively weaponize discrimination and professional medical associations have expressed concerns the rule would allow clinicians to violate their codes of medical ethics.  These criticisms aside what is the theological basis, if any, that would legitimately allow claiming religious or moral exercise in denying health care? 

During this 31 minute conversation the Reverend Patricia Lyons discusses, in sum, that while Christian theological teaching supports the rights of individuals (and their obligation) to follow their conscience, doing so should neither be without consequence as the proposed would allow nor should such protection be used to undermine justice in delivering healthcare without discrimination.  The proposed she Reverend Lyons argues is not workable since it negates the providers obligation in recognizing the inherent dignity of all, undermines their commitment to their profession, erodes the state's obligation in delivering healthcare without prejudice, and altogether is a failure in addressing the common good.     

The Reverend Patricia Lyons is Missioner for Evangelism an Community Engagement, the Episcopal Diocese of Washington, Church House, Mount St. Alban, in Washington, D.C.  She is also an Associate Priest at the Church of the LyonsEpiphany.  Rev. Lyons was for several years chaplain, teacher and JK-12 Director of Service Learning at St. Stephen's and St. Agnes (Episcopal) School in Alexandria, VA.  Reverend Lyons has also taught as an adjunct at the Virginia Theological Seminary.  Reverend Lyons is an honors graduate from Harvard College.  She holds a Master of Divinity degree from the Harvard Divinity School.  She received her doctorate from Virginia Theological Seminary.  Reverend Lyons has published numerous sermons, articles and book chapters on moral and spiritual development theory, as well as consulted for independent schools on moral formation and service learning programs. 

The proposed rule is at: https://www.federalregister.gov/documents/2018/01/26/2018-01226/protecting-statutory-conscience-rights-in-health-care-delegations-of-authority.  

If you're interested in a related essay on this topic, THCB recently posted my essay, "HHS Conscience Rule Would Grant Providers Sweeping Rights to Deny Care," it's at: http://thehealthcareblog.com/blog/2018/03/30/hhs-conscience-rule-would-grant-providers-sweeping-rights-to-deny-care/.

03/15/2018

Author Timothy Hoff Discusses His Latest Work: "Next In Line: Lowered Care Expectations in the Age of Retail - and Value Based Health" (March 14th)

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During this 29-minute interview, Professor Timothy Hoff discusses moreover what market factors explain or are driving the degradation of the therapeutic relationship between the physician and the patient, or what he terms the doctor-patient dyad, these include the "retailing" of medicine, whether "next in line" retail medicine, where we've traded relational trust for calculative trust, is economically rationale, the (negative) effect it is having on physicians and possible solutions to save the physician-patient relationship and raise care delivery expectations. 

Professor Timothy Hoff is Professor of Management, Healthcare Systems, and Health Policy in the D'Amore-McKim School of Business and School of Public Policy and Urban Affairs at Northeastern University.  He is also a Visiting Associate Fellow at Oxford University's Green-Templeton College and a Visiting Scholar at the Said Business School, Oxford University.  Prior to Hoffhis academic career, Dr. Hoff worked for a decade as a primary care practice administrator and as a healthcare consultant.  His research has been published in Pediatrics, Archives of Internal Medicine, Journal of Organizational Behavior, Academy of Management Perspectives, Health Affairs and The Milbank Quarterly.   His research has received rewards from the American Sociological Association, Academy of Management, and the Society for Applied Anthropology.  His previous work, Practice Under Pressure: Primary Care Physicians and Their Work in the 21st Century earned an Outstanding Academic Title award from Choice Magazine in 2010.  He is also co-editor of the 2016 reference volume on transformation in the health professions workforce, it's titled, The Healthcare Professional Workforce also published by Oxford University Press.  Professor Hoff received his undergraduate degree in business administration and his Ph.D. in Public Administration and Policy from the University of Albany.  

For information on Next In Line go to: https://global.oup.com/academic/product/next-in-line-9780190626341?cc=us&lang=en&.

 

03/11/2018

Author Jonathan Engel Discusses His Recent Work, "Unaffordable: American Healthcare From Johnson to Trump" (March 9th)

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During this 30-minute interview Professor Engel discusses moreover why, as he notes, US healthcare is "uniquely dysfunctional," and "laden with profit taking" largely due to induced demand, provides an overview of efforts to contain spending growth via HMOs both in the commercial and the Medicare market, the success of Medicaid HMOs, and discusses his disappointments with the Affordable Care Act (ACA) actually making healthcare more affordable.    

Jonthan Engel is Professor of Health Policy and Management at the Marxe School of Public and International Affairs at Baruch College, CUNY.  He has taught previously at Seton Hall University, Mailman School of Public Health at Columbia University and the School of Public Health at the University of Massachusetts.  He has been a consultant to the White House's President's EngelJonathan-2017.165tAdvisory Committee on Human Radiation Experiments, the lead author on multiple HIV needs assessments for the City of Newark and director of research at the Local Area Board for Health Planning for Essex and Union counties in New Jersey.  His published works include: Doctors and Reformers: Discussion and Debate of Health Policy 1025-1950; Poor People's Medicine: Medicaid and the US Charity Care Since 1965; The Epidemic: A History of AIDS; American Therapy: The Rise of Psychotherapy in the US; and, Fat Nation, forthcoming.   He is currently writing a book on Cold War science and policy in the US.  Professor Engel received his BA from Harvard, an MBA from the Yale School of Management and his PhD in the history of medicine from Yale.  

For more information on "Unaffordable" go to: https://uwpress.wisc.edu/books/5682.htm.

03/04/2018

Unpacking BPCI, CMS' New Bundled Payment Demonstration: An Interview with Dave Terry (February 28th)

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This past January 9th CMS announced Bundled Payment for Care Improvement (BPCI) Advanced.  This five-year Medicare bundled or episode-based payment demonstration, that begins this October 1st, will succeed the agency'a five-year BPCI demonstration that sunsets this September 30th.  BPCI Advanced, also voluntary, will be considerably less expansive than its predecessor in that, among other things, it will include just 32 clinical episodes (29 inpatient and three outpatient), and offer only a single, 90 day retrospective bundled payment under one risk track.

During this 28 minute interview Mr. Dave Terry briefly defines Archway's business model/s, posits what attributes describe successful bundled payment providers, summarizes the findings from a recent study, he coauthored, of BPCI reimbursed total hip arthroplasty surgeries, how CMS has improved bundled payments under BPCI Advanced, or moreover in financial benchmarking and in quality measurement, the legitimacy of criticisms regarding care fragmentation and competition with other pay for performance models and likely success of the demonstration.

Mr. Dave Terry is currently CEO of Archway Health.  Previously, at Partners Healthcare in Boston, Mr. Terry negotiated Terry  Daveglobal cap and pay for performance contracts with managed care plans.  Prior still at Harborside Healthcare, he led a home care agency that managed Medicare and commercial episodes of care within a single payment.  As a partner with The Chartis Group, Mr. Terry developed provider networks and risk sharing models for Medicare Accountable Care Organizations (ACOs).  Mr. Terry holds an MBA from the Harvard Business School and a BA from Columbia University.  He currently serves on the board of Bottom Line, a national educational non-profit, and is a past board member of the Harvard Business School Health Industry Alumni Association.

For information on BPCI Advanced to go: https://innovation.cms.gov/initiatives/bpci-advanced.