Molly Coye (CEO of the Health Technology Center) and Joe Kvedar (Director of Partners’ Center for Connected Health) made a compelling argument for patient-centric health care reform on the Health Affairs Blog yesterday. Coye & Kvedar effectively articulate the rationale and importance of ensuring that our best shot at health care reform in many years improves the care delivery system by focusing on consumers’ health and health care needs. What would have made the piece even more helpful is if they tied that argument more directly to what’s actually going on in Washington, both on the legislative front and in implementation of the American Recovery & Reinvestment Act (ARRA).

Coye  & Kvedar “propose adding two synergistic goals to the policy conversation:

1. Support people in taking shared responsibility for their health outcomes, and make tools available to help them.
2. Pay providers for success in supporting patient self-management, and for preventing the onset or exacerbation of disease, rather than for units of service.”

I completely agree. Although many policy leaders still don’t understand these important points, it’s important to identify where progress has been made and think about how to build on those efforts.

For example, in the implementation of ARRA, the first draft definition of “meaningful use” of health information technology (HIT) includes several patient-centric expectations in order for providers to be rewarded the tens of billions of dollars in incentives in ARRA offers for HIT implementation. If implemented (and strengthened modestly), this approach could have a significant impact on achieving (in Coye/Kvedar’s words) “important transformation of the care delivery process itself, so that patients are fully integrated and in many cases manage their care for prolonged periods with little interface with the physician.”

ARRA also allocated $1.1 billion for comparative effectiveness research (CER). If the CER agenda evolves with five consumer-oriented principles in mind, it has the potential to dramatically improve care delivery effectiveness by providing useful information to consumers and clinicians. The release of the Institute of Medicine’s top 100 priorities for CER provides at least some indication that CER leaders recognize the importance of using these resources to advance patient-centered care.

Although most of the media attention and public debate around health care reform legislation has focused on ideological issues, there is quieter, important work going on with respect to delivery system reform that could pave the way for more patient-centered care delivery. If, for example, the Wyden-Gregg patient decision aids legislation gets integrated into the broader reform bill (and legislators can overcome their ideological divisions and pass something), that could be an important step in the direction of a more rational payment system that encourages information therapy (Ix) — patient-centered care, shared decision making, and participatory medicine. Other important delivery system reforms could be integrated into the final legislation, and I completely agree with Coye & Kvedar that we need to “wrap these concepts [and what they call ‘patient-provider communications tools’] into the implementation of the patient-centered medical home projects and demonstrations.”

It’s important that industry leaders like Coye and Kvedar continue to advocate for achieving patient-centric health care reform. It’s equally critical that we collectively identify practical strategies for integrating those arguments into the development of new bills and the implementation of recently passed legislation.

What are the best strategies for ensuring that health care reform achieves our multiple goals of universal coverage, cost control, and improved quality? I certainly don’t have all the answers, but it’s worth starting with a few, and have all of you build on them.

To be more specific, my primary question here (I recognize there are other ways of framing the discussion for finding answers to the first question) is: What are practical reforms we could make to the delivery system that create better, more patient-centered care delivery at the same time as reducing (or slowing the rate of growth of) costs that free up money to cover un-/under-insured people?

To start with, we can gradually build an expectation of prescribed patient decision aids into the care delivery process. I described a practical model for implementing this model of shared decision making (SDM) here last week in describing new legislation introduced by Senator Ron Wyden (D-OR) and co-sponsored by Senator Judd Gregg (R-NH). The basic idea is to begin with pilots and the development of standards and measures that lay the groundwork for ubiquitous SDM embedded into future care delivery a few years down the road.

We can also take a different approach to how we deal with costly preventable hospital readmissions.  The opportunity here is enormous, which is probably why legislators are seriously considering revamping Medicare payment policy in this area. An Agency for Healthcare Research and Quality (AHRQ) report estimated that hospitals spent almost $31 billion on over 4 million unnecessary readmissions in 2006.  Almost 20% of Medicare beneficiaries are re-hospitalized within the first 30 days of hospital discharge. For heart failure, that figure rises to 27% and in half of those readmissions, there was no outpatient visit billed to Medicare in the month following discharge.

Thankfully, not only is the financial opportunity huge, but the solutions (comparatively speaking) do not require extraordinary measures. During a recent IxAction Alliance webinar, Mark Stewart from the American College of Cardiology (ACC) described the Hospital to Home (H2H) project ACC has developed in collaboration with Don Berwick’s Institute for Healthcare Improvement (IHI). This summer, 1,500 hospitals will engage in the H2H project (as CMS publicly releases hospital readmission rates for the first time) and implement solutions with information therapy (Ix) components such as:

• Pre-discharge education/assessment
• Medication reconciliation
• Follow-up within specific time frames
• Home health involving patient/family education

Success of H2H interventions will be judged primarily by how well patients and their families:

• Understand when & where to seek medical attention
• Can access and are familiar with their medications
• Can schedule and get to their follow-up appointments

ACC and IHI are just a couple of examples of leaders in this area. Content developers such as Krames, Healthwise and Emmi Solutions have created specific Ix interventions focused on reducing hospital readmissions as well.

Beyond patient decision aids/SDM and Ix to reduce hospital readmissions, what other strategies should be integrated into whatever comes out of Congress to reform the health care delivery system? Share your thoughts in the comments below.

I received the following request from NCQA yesterday for the IxCenter to reach out to our collaborators for submissions to Quality Profiles since NCQA recognizes that information therapy (Ix) is a widely used strategy for quality improvement using HIT to address the 6 priority areas below.

Quality Profiles is published annually by NCQA. The overall goal of this series is to provide health care organizations and employers with a rich, up-to-date collection of quality improvement resources, illustrated through best practices, to use as a motivation and foundation for new program development. The seventh edition of Quality Profiles will align with the newly announced national health priorities as defined by the National Priorities Partnership. By highlighting successful ways organizations have incorporated HIT into their patient care processes, this edition of Quality Profiles will help to continue building on the momentum for HIT adoption and implementation.We will include case studies from organizations that will showcase how HIT was used to successfully impact one or more of these 6 areas:

1. Patient & family engagement
2. Population health
3. Safety
4. Care coordination
5. Palliative & end-of life care
6. Overuse

For those organizations that submit applications that involve Ix initiatives to Quality Profiles, we’d appreciate you sharing your best practices with the IxCenter as well. We are in the process of building a methodical library of Ix research, and are collecting as much research as we can both from the peer-reviewed literature and the more organic innovations being developed.

There’s a Letter to the Editor, “Don’t Polarize Health Care,” in today’s New York Times from David Kahn, a psychiatrist at Columbia University, suggesting that the term “perverse incentives” will polarize the health care reform debate. Kahn suggests that a variety of prospective reimbursement arrangements could be described as perverse by others, and such language will only “polarize the difficult discussions ahead.”

I have to admit to having used the term “perverse incentives” from time to time. For example, I do believe that it is perverse at some level that our current reimbursement system, in effect, penalizes clinicians for extra effort invested in patient education, well-structured information therapy (Ix) initiatives, and providing assistance to their patients outside of reimbursable encounters.

Investing resources — perhaps the most valuable clinician resource being their own time — for non-reimbursed care clearly draws resources from those activities for which they can get paid, despite the demonstrated value of tailored health information tools and asynchronous communication. I do see perversion at work there.

Whether eradicating inflammatory phrases from our vocabulary will lead to a less polarized debate environment or merely reduce the urgency for delivery system reform remains to be seen. If the former were true, I’d take an immediate pledge to swear off use of such phrases. Until then, I worry more that the pull of inertia remains strong enough to maintain the status quo — which includes a somewhat perverted payment structure.

Happy New Year!

So much excitement is on the horizon in the new year. Here are five IxCenter priorities for 2009:

• The intersection of information therapy (Ix) and Health 2.0
  • There has never been a conference like the upcoming first-ever “Health 2.0 Meets Ix” Conference in Boston April 22-23!
• More intensive efforts in Ix implementation in safety-net populations
  • New IxAction safety-net providers as well as a few potential new Ix grant projects with underserved populations have great potential to show the reach of Ix initiatives.
• Building the Ix infrastructure in the context of health care reform
  • How do we build on 2008’s Ix private sector infrastructure successes by developing Ix-oriented performance measures and integrating these efforts into the national health care reform debate?
• More detailed exploration of Ix strategies for Rx management
  • What is the role of Ix in improving medication management, reducing medication errors, and streamlining medication selection decisions?
• Deep dives on key Ix applications
  • These may include pre-visit prep, after-visit summaries, prevention reminders, decision aids, and others.

What matters most to you as we work to advance the practice and science of information therapy in 2009?

Last week’s New England Journal of Medicine had a Perspectives piece by Meredith Rosenthal, “Beyond Pay for Performance — Emerging Models of Provider-Payment Reform.” Rosenthal does a reasonably good job of summarizing progress thus far but she omits an important consideration in structuring reimbursement to encourage the provider behavior we desire.

Not nearly enough has been done thus far to encourage and hold providers accountable for communication with, and engagement of, their patients. We know that high-quality health care is partially (and substantially) based on effective communication, patient understanding, and consumer engagement (several posts on this blog have cited relevant studies in support of this fact). However, most pay-for-performance (P4P) models don’t explicitly try to address this issue.

To provide an instructive example of an exception that proves the rule, look at the MedEncentive approach. It provides two types of incentives. It rewards physicians for prescribing information therapy (Ix) and following evidence-based guidelines (or explaining why they don’t in specific circumstances).

Second, and unlike other P4P approaches, it also offers incentives to patients for filling their information prescriptions (going to the URLs where relevant evidence-based information is provided) and for confirming through a brief survey that their clinicians communicated appropriately and effectively with them. Preliminary results from MedEncentive suggest not only significant cost savings and high patient satisfaction but also a shift in payment from more intensive to less intensive settings, one of the goals of payment reform noted by Rosenthal.

In her article, Rosenthal summarizes the P4P/payment reform body of research, “There are, fundamentally, no ‘new’ methods of health care payment.” On the other hand, she didn’t describe the dual-incentive (patient as well as provider) approach and didn’t discuss much about how to enhance patient-physician communication and consumer engagement.

As payment reform initiatives evolve, particularly with the renewed popularity of the old idea of the patient-centered medical home (known by other names in the past), it’s important that these patient perspectives on performance are measured and rewarded.

There was an essay by Sandeep Jauhar, MD, in yesterday’s New York Times about the perils of pay-for-performance (P4P). Specifically, Dr. Jauhar discusses how P4P may have unintended consequences and create perverse incentives due to poorly designed performance measures. The point is well taken, but it’s important not to confuse the merits of P4P with the measurement issues that exist.

With respect to the latter, back in my days as Director of Measure Development for the National Committee for Quality Assurance (NCQA), I co-authored a paper with Partners’ cardiologist Tom Lee, Jim Cleeman from NHLBI, and others working with us at NCQA on the development of new HEDIS cholesterol management performance measures. In the JAMA article, “Clinical Goals and Performance Measures for Cholesterol Management in Secondary Prevention of Coronary Heart Disease,” we tried (among other things) to communicate the difference between quality improvement measures and comparative performance measures.

Although the multi-stakeholder Cardiovascular Measurement Advisory Panel and NCQA’s measurement policy-making body, the Committee on Performance Measurement supported the goals of NHLBI’s practice guidelines, we believed that there are signficant differences “between a clinical goal for the management of individual patients (LDL<100 mg/dL) and a performance measure used to evaluate the care of a population of patients (LDL<130 mg/dL).” We described several reasons including: gaps in reasearch; drug efficacy; realistic performance measures; simplicity; and implications of physician failure.

Measurement systems designed for internal quality improvement may very well be different from those used to compare provider quality for a diverse population of patients, and we should make sure to consider the differences in establishing the criteria by which clinicians are compared and reimbursed.

However, we can make those distinctions and we need to in order to drive different kinds of quality improvement forward. If we don’t create fair measures that differentiate provider performance, we will continue to lack ways of adequately compensating those who deliver care for anything but the quantity of what they produce (i.e., number of services provided).

Certainly one of the best ways we have to assess patient-centered care is to ask consumers about their own experiences via scientific surveys. As I noted last week about Medicare publicly releasing HCAHPS data on patient experiences with hospital care, health care’s powers that be are emphasizing patient-reported data more than ever.

URAC has just released for public comment a new case management patient satisfaction tool, which is an important step forward in driving a patient-centered approach to delivering those services. Much of the tool is good.

Question #7 could be strengthened by drawing out more specific input from patients about the kind of information that helps people manage their care. It asks patients to rate agreement with the statement, “My Nurse/Case Manager provided verbal and/or written information that helped me reach my goals.”

We should have an expectation that case managers employ more than just live, oral communication to help people reach their goals. For that reason, the “or” is inadequate.

In some cases, however, “written” may not be sufficient either, given that it implies text. For some people, graphics, video, or audio may be more effective media. Perhaps most importantly, it should be information that the patient can save and refer to at his or her convenience.

Although the wording may still need work, better language to address patient-centered communication needs would be, “My Nurse/Case Manager provided information in a form that I could understand, access when I needed it, and helped me reach my goals.”

One thing that’s clear from a new study by Jack Fowler in this week’s JAMA is that hospital patients’ experience with care is unrelated to health care expenditures. Given how much we spend on health care in the US, we ought to figure out how to make it positively affect consumers’ experiences.

At our 7th Annual Ix Conference, “Next-Generation Patient-Centered Care,” we will address patient-centered communication and the incentives to encourage it from multiple angles. You can still register for this unique event in Washington, DC June 12-13.

An Associated Press story published today highlights a new CMS (the federal government agency that administers Medicare and Medicaid) advertising campaign to improve quality and transparency for US hospitals. This marks the first year that CMS has publicly released HCAHPS data on hospital patients’ experience with care.

The HCAHPS (Hospital Consumer Assessment of Health Providers and Systems) survey may begin to build a business case for hospitals to focus more intently on delivering more patient-centered care and information therapy (Ix). NCQA’s (National Committee for Quality Assurance) HEDIS public reporting efforts have dramatically improved health plan performance on a range of quality indicators, and CMS is optimistic that its Hospital Compare tool can do the same for hospitals.

Several HCAHPS questions have the potential to drive Ix and patient-centered HIT initiatives in the inpatient setting. Most notably:

• How often did nurses explain things in a way you could understand? (Q3)
• How often did doctors explain things in a way you could understand? (Q7)
• Before giving you medicine, how often did hospital staff tell you what the medicine was for? (Q16)
• Before giving you medicine, how often did hospital staff describe possible side effects in a way you could understand? (Q17)
• Did you get information in writing about what symptoms or health problems to look out for after you left the hospital? (Q20)

There are other important market drivers of inpatient Ix. JCAHO has existing standards that reinforce the need for Ix, and hospitals have reported to the IxCenter that JCAHO reviewers have been more strongly emphasizing the need to document Ix delivery. Specifically, the Comprehensive Accreditation Manual for Hospitals (CAMH) includes 12 references to atient education as services that JCAHO expects hospitals to instruct patients on during their hospital stay. Among the most relevant patient education items in JCAHO are:

• LD.3.15 – patients admitted to a temporary location must have rights and access to services
• LD.3.120 – leaders plan and support patient education
• PC.6.10 – patient receives education and training specific to patient’s needs
• PC.6.30 – patient receives education and training specific to patient’s abilities

The issue of “aligning incentives” and creating market rewards for Ix is one of the topics that we will be addressing June 12-13 at the 7th Annual Ix Conference, “WIxRED: Next-Generation Patient-Centered Care” at the Newseum in Washington, DC.

Will the biggest disruption in health care be an Internet-based health care industry? We already know that more consumers get answers to their health care questions on a daily basis from the Internet than from their doctors. But do we think that online tools will evolve enough to allow consumers to organize and make sense of that information without trained professionals?

Will the trend toward “convenience care” (pharmacy- or mall-based walk-in clinics) have the greatest impact on how providers organize care delivery? Will they need to re-think the way they practice medicine to meet new consumer expectations?

Maybe CMS’s requirement that hospitals begin publicly reporting patient experience data in 2008 will forever change how hospital view patient-centered care. Will hospitals finally find that being truly patient-centered has a business ROI?

Will consumer control over their own health information via personal health records (PHRs) alter the historical information asymmetry and allow them to control their own health care lives? What needs to be done to make sure that PHRs actually fulfill their potential as a disruptive force given that personal health data availability by itself will have a marginal impact?

Will the evolution of electronic health records (EHRs) and a robust interoperable health information exchange dramatically change health care by increasing connectivity among systems, providers, and others? Or, will we just create a process for transferring 1’s and 0’s on top of poor models of health care delivery?

Will the boom in biomonitoring/wireless devices (the so-called “healthcare unbound” space) revolutionize health care by allowing consumers to access the health care they need anytime, anywhere, and any way they want it?

Maybe the answer lies in more ubiquitous technologies. Could expanded use of cell phones and the application of tailored automated telephony allow us to reach a broader audience more conveniently, thus increasing the likelihood that average consumers will be more activated about their health care needs?

Can we more effectively engage consumers in better managing their own health by learning from Hollywood or video games about how to draw people in through entertainment? By doing so, can we make health care “fun” or at least truly engaging?

Can we find new payment structures to eliminate the perverse incentives that plague our current health care delivery system? Or, will people find ways to game any new system we design…or will entrenched interests simply prevent new systems from coming into fruition?

Is there any hope at all for finding a way to cover the growing number of uninsured in the country given the politically changed environment in Washington?

What is the role of information therapy (Ix) in each of these potentially disruptive forces?

Which of these developments will have the biggest impact on health care? Beyond that, will any of them actually change a system that has so many challenges and problems?

Many of these questions will be tackled at our upcoming Ix conference October 8-10 in Park City (see http://guest.cvent.com/EVENTS/Info/Agenda.aspx?e=f586de48-3d6e-4064-8543-1c7037b58890 for the full conference agenda). I hope you’ll join us.

–Josh