Good News

IN THE STATES: Comparative Effectiveness in Minnesota

Meredith Hughes — Thu, 12 Nov 2009 19:49:00 -0500

What is comparative effectiveness research? If you need a reminder: comparative effectiveness means comparing two or more treatments for the same health problem to see which one works best for patients. The question has popped up quite a bit since comparative effectiveness research showed up in the economic stimulus package alongside other common sense health reforms, such as health IT adoption. Comparative effectiveness is about giving doctors and patients more information and facts for decision-making, not about taking away their autonomy.

Here's a real world example that's worth noting. The Institute for Clinical Systems Improvement (ICSI) in Minnesota is an example of an independent (private), non-profit organization that works to assemble and disseminate comparative effectiveness research. Clinicians in ICSI review medical literature and make recommendations about the most cost effective treatments based on the best available evidence. HealthPartners Medical Group, the Mayo Clinic, and Park Nicollet Health Services jointly founded ICSI in 1993. ICSI is made up of 57 member organizations and is funded by seven Minnesota and Wisconsin health plans. (The research funded by the federal stimulus bill looks at effectiveness, and doesn't make recommendations based on cost.)

ICSI maintains a list of evidence-based health care guidelines to encourage member organization to adhere to the best clinical practices. When better evidence comes along, previous guidelines get retired to make way for higher standards of care. For example, the most recent ICSI report updated care guidelines in several categories:

Obesity Guidelines. Because obesity presents such significant health concerns for the U.S., the Prevention and Management of Obesity in Mature Adolescents and Adults Guideline workgroup revised this document in 2008 to provide a more multi-faceted approach. It updated information on body mass index (BMI) and co-morbid conditions to include approaches to weight loss for each BMI category. Content and clarifying language were added to the waist circumference annotation. Conclusion grading worksheets on physical activity and low carbohydrate diet were incorporated into the related annotations, and one on surgical approaches to weight loss was added to the guideline.

Preventing Chronic Disease Through Primary Care. The guideline defines strategies and programs providers, communities, payers and employers can offer to support patients to make essential changes in four behaviors that contribute to roughly 40 percent of all deaths in the U.S. -- poor nutrition, physical inactivity, smoking and hazardous alcohol consumption. As a result, its recommendations are being used to address conditions like prediabetes, and are seen as a preventive component of care in health care homes.

Surgical Protocol: Before, During, and After an Operation. ICSI significantly revamped this protocol to describe all the steps performed throughout the pre-, intra- and post-operative periods of surgery. The protocol outlines the processes involved in obtaining patient consent, and verifying and marking the surgical site. It addresses the prevention of site infection for numerous surgical procedures, starting with the preoperative evaluation and surgical planning and proceeding through the perioperative period.

Guidelines and protocols describing the best standards of care are the primary goal of ICSI, though they also provide support for member institutions through strategic initiatives such as DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction). DIAMOND is a collaborative care model that emphasizes depression detection and treatment. The program has six components:

A checklist that helps the care team detect and monitor symptoms of depression (ICSI discovered that most primary care physicians only pick up about half the cases of major depression in their patients)
A way for the care team to monitor the depressed patient
A proven medical guide to know how best to change or intensify treatment
Tools to keep a patient who is getting better from falling back into major depression
A care manager to educate and help the patient reduce depression symptoms and improve functioning
A psychiatrist to review patient cases with the care manager and consult with the primary care physician on any recommended changes in treatment

ICSI member organizations Community-University Health Care Center, Family HealthServices Minnesota, HealthPartners, Mayo, and SuperiorHealth Center launched the DIAMOND program in just 10 primary care clinics in early 2008, and by September, the program had spread to approximately 30 clinics serving 1,000 patients. According to ICSI, after six months in the program 47 percent of depression patients were in remission, and an additional 12 percent showed significant improvement.

ICSI's experience in Minnesota shows us that comparative effectiveness research can be a great tool for health care quality improvement. By working together and committing themselves to the most up-to-date, evidence based treatment guidelines, ICSI member organizations are able to provide high-quality, patient-centered care.

WHAT WORKS: Highlighting Health Care Success Stories

Meredith Hughes — Fri, 18 Sep 2009 20:40:00 -0400

Want to learn more about how innovators are leading the way toward a higher quality, lower cost health care system? See our updated What Works page, where we feature health care success stories from across the nation.

What Works showcases both big initiatives and small success stories. Check back often for the latest analysis and news.

QUALITY: The Right Stuff, From Coast to Coast

Meredith Hughes — Tue, 25 Aug 2009 19:40:00 -0400

Newspapers are abuzz with the daily drama of health politics. But we're also seeing good news -- stories highlighting health care success stories. High performing health systems across the U.S. show us that our goals for health reform -- high quality, low cost, and coverage for all Americans -- are possible. And in a reformed health care system with better and more sensible incentives and payment systems, we'll see even more innovation. These health systems might not be launching anyone into space, but they are caring for people, a job that requires just as much precision and thoughtfulness. They've got "the right stuff.'

Group Health Cooperative and Kaiser Permanente Northwest. Both health systems drew attention recently when Sen. Kent Conrad (D-ND) proposed co-ops as an alternative to a public health insurance option. The key to their success is spending more money up front on primary and preventative care, rather than waiting for health problems to become more serious and more costly, reports The Portland Oregonian. (We at New America have also worked with Group Health on Health Care CEOs for Health Care Reform.)

Group Health expanded their primary care staff by 30 percent to for better care coordination, and to give patients more time with doctors. The medical home model emphasizes preventative care -- the kind that keeps patients healthy, but isn't emphasized or well reimbursed in our traditional fee-for-service model. When doctors spend more time with their patients, doctors are happier and patients are happier and healthier. The investment in primary care paid off for the Group Health Cooperative in many ways. They saw a 30 percent reduction in ER admissions and an 11 percent reduction in avoidable hospital admissions, while quality and employee satisfaction went up. Those savings more than cover the investments in primary care, Group Health CEO Scott Armstrong said at an event on Capitol Hill earlier this summer.

Virginia Commonwealth University Medical Center. House visits are making resurgence in medical care, in more places than one. The latest comes from the VCU Medical Center in Richmond, VA, reports the LA Times. House visits allow doctors and nurses to stay in touch with patients by visiting them in their homes -- performing routine health check ups, asking and answering questions, and helping patients manage and adhere to treatment routines, such as taking their medication on time. Home visits are most helpful to those that are most vulnerable. It's often difficult for the elderly, or those with one or more chronic illnesses, (or both) to visit the doctors' office for a routine check up.

Helping vulnerable populations adhere to their prescribed treatment routine keeps them out of the hospital -- so patients stay healthier, get better, more personalized care, and the hospital actually saves money. Ten percent of Medicare beneficiaries account for almost two-thirds of Medicare spending, reports the LA Times. Though Medicare only pays for half of the home visits, VCU Medical Center covers the rest of the cost.

The LA Times also writes health reformers are considering making house visits a part of health reform. "This is one of the most promising ideas I have seen," Elaine Ryan, a vice president at AARP, told the LA Times. "It is not only a cost saver...it is something that addresses really the most critical issue for Medicare beneficiaries."(We've blogged about home visits several times, including here, here and here).

Geisinger Health System. Geisinger, a health system in rural PA, is mentioned often in conversations about high quality, low cost, innovative health care. Geisinger expands its quality care model, Proven Care, incrementally but continually. In the past, Geisinger improved widely utilized procedures such as hip replacement or cataract surgery by studying the procedure, coming up with a step-by-step formula for best practice (with flexibility where necessary), and paying a flat rate for each procedure. This saved money and improved quality, such as patient outcomes. Geisinger continues to improve and innovate, reports The Philadelphia Inquirer,

One of [Geisinger's] programs, Proven Health Navigator, gives Geisinger primary-care doctors a nurse who oversees the most chronically ill patients. By closely monitoring such measures as blood sugar levels, the nurses keep emergency-room visits -- and costs -- down. Another Geisinger program guarantees the price of heart surgery, recovery, and therapy from the day of diagnosis until 90 days after the operation, giving doctors and other providers incentives to avoid errors.

(The Washington Post's Ceci Connolly has also written about Geisinger, and so have we.)

For more real world examples of excellent health care delivery, check out our "What Works" page -- and then check back again as we're going to keep adding information.

HEALTH CARE: What Grand Junction Colorado Can Teach the Rest of Us (Part 2)

Joanne Kenen — Fri, 14 Aug 2009 13:29:00 -0400

Grand Junction, CO, is the high-quality, low-cost flip side of McAllen, Texas in Atul Gawande's recent New Yorker article. New America's health policy team just published a case study on how Grand Junction's health care system evolved (full paper here, summary here), and what the rest of our country can learn from it. We gave you an overview on our blog Thursday. Now we're going to look at how the community uses health IT to create quality and value.

We all know that health IT in and of itself isn't a cure-all. But it's hard to fix health care without smart use of health IT across the community.

One of the unusual features about the Colorado community is that the main health plan (Rocky Mountain Health Plans) pays a "blended rate" to physicians. That means it's a similar rate for private insurance, Medicare, and Medicaid. Doctors thus don't have any incentive to cherry-pick better paying privately insured patients, and shun the poor. Everybody gets care. The community benefits.

Rocky ended up in a lawsuit with the state Medicaid program a few years ago and got a $21 million judgment for underpayment in the 1990s. Rocky divvied up most of the money among physicians it contracted with, but a dispute arose over $2.5 million. The solution? Spend the money on something that would benefit the community as a whole. Rocky was already helping physicians install electronic medical records in their offices. Now they would go a step further and create a community-wide system. The Quality Health Network went live in 2005, and is now nationally recognized.

Today, the network serves western Colorado and eastern Utah. It is a community-wide effort, with a board of directors and several subcommittees of leaders from all areas of the health care community. About three-fourths of its funding comes from the community's two hospitals, Rocky, and the Independent Physicians Association of Mesa County. (Our case study explains more about the unusual degree of cooperation between these key health care players).

The health IT network's roots actually go back about 15 years, when Rocky and the IPA doctors wanted to have one place to access information about patients who see both specialists and primary care providers. But it was early in the information age, and the first attempts failed. About three years ago, they tried again. Now network users include physicians and hospitals, clinics, hospice, long-term care facilities, mental health providers, home care agencies, physical therapy, occupational therapy, schedulers, labs, transcriptionists, case managers, and insurers. As of February 2009, there were 1,569 licensed users from 84 different organizations, including the public health department. In just the first two months of 2009, there were more than three million requests of the server. In June 2009, western Colorado was granted $4 million to install a QHN system that would connect outlying areas with an Internet database for physicians to access patients’ medical histories.

Health IT is a big boon to Grand Junction's providers. They get to see a complete picture of their patient. The cardiologist, for instance, knows what the pulmonologist prescribed, what tests were done. The hospital knows what the outpatient community-based care providers did and vice versa. There's less risk of harmful drug interactions if all the doctors can see the complete records. Less duplication of expensive tests and imaging. Better coordination of care. Fewer unnecessary hospitalizations. Higher quality. Lower cost.

Grand Junction's use of health IT shows us what we should all be striving for.

HEALTH CARE: What Grand Junction Colorado Can Teach the Rest of Us (Part 1)

Joanne Kenen — Thu, 13 Aug 2009 19:23:00 -0400

McAllen, Texas, became a buzzword for high health care spending after Atul Gawande's recent New Yorker article. Less attention was paid to Grand Junction, Colorado, which that same article held out as a model of high-quality, low-cost care. President Obama plans to visit Grand Junction and see for himself this weekend.

How did Grand Junction become one of the nation's highest performing health care communities? We had heard about Grand Junction months ago, and began wondering about that ourselves. So for the last few months some of the New America health team has been studying the data, and talking to participants. We just released the case study: "Grand Junction, Colorado: A Health Community that Works."

You can read a summary here or the full paper here. Today and tomorrow on the blog, we'll l share some of the highlights.

Some of what Grand Junction does right can be replicated -- i.e. having a state-of-the-art health information technology system that many providers can access from a variety of settings to get a full picture of a patient's condition, medications, test results, and health history. Some may be a bit harder, such as forward-looking leaders in health care that have a strong sense of purpose and community, and who figured out how to align incentives and business practices so that what's good for the key players in health care was also good for the community as a whole -- including the sick and the uninsured.

"One of the most impressive things about Grand Junction is its ability to channel self-interest to serve societal interest. This is a major goal of comprehensive health reform," said Len Nichols, director of the health policy program at New America.

The case study analyzes features of Grand Junction health care including::

Quality over quantity. Incentive contracts between physicians and the area's largest insurer help move providers away from fee-for-service, pay-for-volume reimbursement. High quality care is rewarded -- particularly if it's high quality and efficient.
A safety net that not only catches but embraces the needy. A clinic for the uninsured is located on the grounds of one of the major hospitals in the community. Eligible uninsured patients who show up in the ER get transferred over to the clinic for follow up or ongoing care, with care provided free or on a sliding scale. The clinic offers them a same-day, one-stop shopping for primary, preventive and behavioral health. If they need to see a specialist, the clinic can call on a network of volunteers. The coordinated safety net reduces the cost (and cost-shifting) of caring for the uninsured. Every patient receives quality care regardless of income or insurance status.
Transparent performance data, peer-to-peer feedback, and information sharing that encourages doctors to collaborate and communicate. Physicians learn how much each test, drug, specialist referral, and hospitalization cost the health plan. This transparency, coupled with quality measurement, raises physicians' cost-consciousness, and, along with the incentive contracts, channel physicians' competitiveness into efficiency rather than revenue maximization.
A strong primary care physician workforce that coordinates treatment. Team-based care is common, and the health IT enables disease management and care coordination among multiple physicians and facilities. Primary care doctors are encouraged (and compensated) for seeing their patients in a hospital, even if they are under the care of a specialist. That promotes good communication and smooths transitions and follow-up care from hospital back to the community.
Innovative community service organizations that play a key supporting role in filling the community's health care needs from birth to death. Make that even before birth: prenatal care is excellent and available to benefit the next generation of Grand Junction residents.

Tomorrow, we'll look at some other aspects of what the community is doing right -- and what the rest of the country can learn about getting to high-quality, lower-cost health care faster than we might have imagined.

QUALITY: Baylor Best at Heart Failure -- By a Mile

Tom Emswiler — Fri, 10 Jul 2009 15:12:00 -0400

Thanks to a new commitment to transparency by the Centers for Medicare and Medicaid Services, this week was a giant leap forward for health care consumerism. We learned exactly which hospitals have very good, so-so, and very bad rates for three clinical conditions in terms of deaths and readmissions: heart attack, heart failure, and pneumonia. For anyone reading this new to health policy research, let me tell you: this is huge.

In fact, USA Today boldly states: "The analysis represents the most statistically powerful portrait of hospital performance... in the history of U.S. medicine." The national daily has put together a great interactive tool with Google Maps so that you can easily (and I mean easily!) compare these indicators for the hospitals near your house... or your parents' house... or anywhere in the United States.

The paper also ran a companion piece highlighting the hospital with the best (lowest) heart failure readmission rates. It's Baylor University Medical Center (BUMC), the flagship hospital of the Baylor Health Care System, and we've written a lot about Baylor before for good reason. The medical center's heart failure readmission rate is 15.9 percent within 30 days of being discharged. Compare that with the national average of about 25 percent. This is a lot of people, too -- it's the number one reason Medicare beneficiaries are admitted to the hospital in the first place. (My colleague Joanne Kenen has written recently about readmissions and innovative ways of keeping patients healthier at home).

Why is this such an accomplishment for Baylor? It's simple -- they're the best by a mile:

"They're not only the best in the country, they're the best by 2 percentage points," says Yale cardiologist Harlan Krumholz, who developed the statistical methods used in the Medicare analysis with Harvard's Sharon-Lise Normand and others. "Two points in this analysis, where we were so conservative, is huge. It's like winning the Kentucky Derby by a quarter of a lap."

OK, so maybe they're the best by a quarter mile, but still, how'd they do it? As the article states, physicians and staff don't think of a discharged patient as off their radar. They aggressively follow-up with patients and their post-acute care facilities to make sure orders and instructions are followed.

It also saves Baylor money. According to CEO Joel Allison, their standardized heart failure treatment plan saved the hospital $1,800 per admission; this would translate to $1.8 billion if the one million heart failure admissions in the U.S. were treated by these protocols. We covered Baylor's four-part heart failure implementation action plan in our paper published in March by The Commonwealth Fund.

Jack Lewin of the American College of Cardiology and Donald Berwick of the Institute for Healthcare Improvement tell USA Today the real challenge is how to get the BUMC methods to the worst and middle-ranked hospitals. We hope that the new federal comparative effectiveness funding will help move us toward that goal. But it's also worth considering how the Baylor system was able to disseminate the information to its own physicians and staff. It uses a Best Care Committee to pass rules on how evidence based care should be delivered at Baylor facilities and then uses Physician Champions to implement them.

Think this can only happen at Baylor? While they have some unique characteristics, most hospitals today are part of a regional or national chain. These systems have the ability to do something similar to the Best Care Committee and Physician Champions. And they should. As of now, their patients are watching.

GOOD NEWS: How the Baylor Health Care System Disseminates Quality Improvement (Part III)

Tom Emswiler — Wed, 01 Apr 2009 11:00:00 -0400

(This is the sixth and final installment of our blog series on our recent papers on health care quality published by The Commonwealth Fund. Last week we focused on the Hill Physicians Medical Group. This week we look at Baylor Health Care System, a nonprofit integrated delivery system based in the Dallas/Fort Worth area.)

We've already learned about Baylor's Best Care Committee and its physician champions. Now let's wrap up with a look at Baylor's innovative training program and the exportable lessons.

ABC-Baylor

As you know, senior members of Baylor and its HealthTexas Provider Network traveled to Intermountain Health Care in Utah several years ago to see first hand the systemic quality improvement that reformed its delivery of health care. Inspired, the attendees returned to Baylor and created the Physician Champions program and their own Quality Improvement education program.

Patterned after the Intermountain model, Accelerating Best Care at Baylor (ABC-Baylor) began in January 2004 with help from Intermountain's Brent James. It features a six-day seminar designed to provide the tools for rapid-cycle process improvement throughout the Baylor system. When physicians and other health care professionals have data, strategy, and a goal, the health of their population can improve.

As an additional incentive to its providers, Baylor's Quality Improvement Award Program offers multidisciplinary teams cash prizes for demonstrating sustained quality improvement. More than 600 clinicians, administrators, and board members have graduated from the full six-day ABC Baylor course, and more than 500 unit nurses have completed ABC Fast Track, the one-day accelerated version of the program.

Three Exportable Lessons

Physician Leadership Is Critical. Baylor administrators get physician cooperation in part because they pay for it. As described earlier, the Physician Champions program pays early adopters of quality initiatives and EHRs on a part-time basis to positively influence their peers. As Dr. Couch, the lead Physician Champion, states: "It is unrealistic to expect practicing physicians to dedicate significant time to help the healthcare system advance quality unless compensated for that time."

Board Leadership Is Critical. Baylor's Boards of Trustees have made quality improvement a priority. Their leadership includes setting targets for reducing mortality, as well as setting participation goals for such quality initiatives as the Institute for Healthcare Improvement's 100,000 Lives Campaign. Similarly, a staffer for Premier, Inc. reported that board commitment was essential for success in its Hospital Quality Incentive Demonstration project. A priority for the board becomes a priority for the organization.

Quality Needs an Answer to "Who Says?" The Best Care Committee is the clinical authority for the entire Baylor system. Its research, deliberations, and decisions are based on the tools Physician Champions use to improve the quality of care that the patients receive. In addition, information about evidence-based medicine needs to be available to Physician Champions so that they can work with their peers.

You can find the overview for this series here, and the Hill posts here and here.

GOOD NEWS: How the Baylor Health Care System Disseminates Quality Improvement (Part II)

Tom Emswiler — Tue, 31 Mar 2009 14:05:00 -0400

(This continues our blog series on our recent papers on health care quality published by the Commonwealth Fund. Last week we focused on the Hill Physicians Medical Group. This week we look at Baylor Health Care System, a nonprofit integrated delivery system based in the Dallas/Fort Worth area.)

Yesterday we looked at Baylor's Best Care Committee's role in quality. Today we'll turn to physician leadership.

Physician Champions

After what was evidently an inspiring site visit to Intermountain Health Care in Utah earlier this decade, the HealthTexas Provider Network (the 450-member physician group owned by the Baylor Health Care System) appointed five ambulatory care "Physician Champions" to join the initial set of Baylor's hospital clinical champions who had been appointed in 2000. Physician Champions contractually agree to commit between four and 16 hours per week to support Best Care initiatives. They are paid by the hour and have specific expectations and duties. Some are HealthTexas physicians and some are other affiliated physicians who have patients at Baylor. They are paid below their standard market rate, but well enough to demonstrate that respect for their time (via compensation), combined with commitment to purpose, results in strong engagement. The Baylor system now has dozens of Physician Champions.

Physician Champions' duties include graduating from ABC Baylor (to be discussed tomorrow); influencing peers to adopt Best Care Committee initiatives; developing standardized order sets for a specific diagnosis or condition; helping define measurable clinical, financial, and patient satisfaction outcomes; being responsible for their improvement on a local level; and serving as needed on the Best Care Committee.

HealthTexas has a formula for success (literally). To inspire change among a certain number of physicians (numerically represented as N) requires a number of leaders equal to the square root of the total (√N). That means that 58 physician champions were needed to effect change among the 450 HealthTexas members, plus 3,000 additional physicians practicing at Baylor hospitals. Baylor budgets three million dollars annually to recruit, train, and pay these champions to implement Best Care measures and EHRs.

HealthTexas Quality Committee

As Dr. Carl Couch writes in a recent Physician Champion Annual Report, "Alignment with physicians is nationally recognized by hospitals as a critical success factor in health care delivery and quality improvement." The Baylor system achieves this coordination with its employed physician group, HealthTexas Provider Network, as well as through a broad range of other physician relationships. Specifically, Baylor's facilities work closely with the HealthTexas quality committee to improve physician performance in the delivery of clinical preventative services.

Working with Dr. David Ballard, who had been recently hired as the Baylor system's first Chief Quality Officer, the HealthTexas quality committee first focused on a practice area that had been vastly under-delivered: Adult Preventive Health Services, also known as Clinical Preventive Services. In 2007, Dr. Ballard and colleagues published the results of Baylor's focus on preventive services. By increasing productivity through 11 interventions—ordered sequentially to further enable the provision of these services at each step—the delivery or recommendation of clinical preventive services rose from 68 to 92 percent from 1999 to 2006.

Shortly after this study began, Baylor began measuring the actual delivery of those preventive services. HealthTexas physician reports and quality initiatives focus now only on delivered preventive services because the network's leadership believes physicians should be held accountable for care that is delivered, not simply care that is "recommended or delivered." From 2001 to 2008, the delivery of these services rose from 68 to 82 percent, reaching as high as 84 percent. Baylor physicians, however, have thus far not been able to break through that 84 percent ceiling, which has been ascribed to the limits of its paper-based processes. Leaders are considering how to deploy decision support tools, which are components of the ambulatory electronic health record software, for improved delivery of clinical preventive services.

(Source: BHCS)

GOOD NEWS: How the Baylor Health Care System Disseminates Quality Improvement (Part I)

Tom Emswiler — Mon, 30 Mar 2009 12:46:00 -0400

(This continues our blog series on our recent papers on health care quality published by the Commonwealth Fund. Last week we focused on the Hill Physicians Medical Group. Now we turn to Baylor.)

Baylor Health Care System (BHCS) is a nonprofit integrated delivery system based in the Dallas/Fort Worth area. Len Nichols and I have profiled their work improving quality through a multitude of initiatives in a just-released case study published by The Commonwealth Fund.

Founded more than a century ago, Baylor Health has grown from a one-building hospital to a 3,000-bed integrated system that uses electronic health records and numerous quality improvement tools. The system owns a 450-physician medical group subsidiary and is affiliated with 3,000 independent physicians who deliver care at 15 Baylor-owned, leased, or affiliated hospitals and six "short-stay" hospitals. Baylor uses training programs, as well as physicians, to encourage system-wide initiatives and cement its quality mission across the entire system. The system has successfully implemented electronic medical records, decreased mortality rates, and standardized care.

Highly-esteemed integrated systems like the Mayo Clinic are sometimes derided by health reform pessimists as laudable organizations that exist purely because they reside in remote areas or were founded before 21st century business pressures. Baylor, however, demonstrates that substantial health care delivery improvement can occur in just a decade.

This is the first of three posts on the Baylor Health Care System. Today we'll look at the Best Care Committee, tomorrow we'll discuss physician leadership in quality, and finally we'll examine their innovative training program and look at the exportable lessons.

Best Care Committee

Integral to Baylor's quality improvement strategy is the Best Care Committee. Formed in 2001, the Best Care Committee began as a forum to define, discuss, and develop implementation strategies for care improvement initiatives. In March 2005, the committee was re-formed to become a legislature-like body with more than 100 voting members.

The Best Care Committee's current co-chairs are the chief medical officer and the chief nursing officer of the Baylor system. Members includes the system's chief quality officer, patient safety officer, and chief medical informatics officer, as well as hospital presidents, chief nursing officers, medical staff presidents, health care improvement directors and chief operating officers. Other members include Physician Champions (to be discussed tomorrow), nursing leaders, and others representing the patient safety, equity, patient-centeredness, finance, and business development areas of Baylor.

Since March 2005, the Best Care Committee has passed more than two dozen major quality initiatives. Committee members take on the responsibility of implementing these initiatives at their home hospitals. The ground rules state: "Once the BCC passes an initiative, it is to be adopted across all facilities; BCC members will promote the adoption of these Best Care initiatives across all facilities; adoption and impact will be monitored and used to promote continuous improvement of the care that we deliver." In other words, as Baylor Health's Physician Champion leader Dr. Carl Couch told us, the committee becomes the answer to "Who Says?" As Baylor Health's clinical authority, it is the chief counterargument to the statement of local autonomy, "That's not the way we do it here."

The Best Care Committee has no explicit executive authority. It achieves success via persuasion, common alignment of goals, and focused implementation efforts. Committee initiatives are not enforced, but are implemented. This is accomplished through a monthly reporting of process and/or outcome metrics to the Best Care Executive Committee, local hospital committees, and ultimately to the hospital and system boards. Implementation is driven by "Physician Champions," who are recruited from Baylor's physician ranks and, importantly, are compensated for the time they devote to quality initiatives.

The Best Care Executive Committee establishes the strategy and agenda for the full committee, and ensures that it follows the six aims established by the Institute of Medicine: care that is safe, timely, effective, efficient, equitable, and patient-centered. The Executive Committee also steered the committee as Baylor participated in the Institute for Healthcare Improvement's 100,000 Lives Campaign. Although the Campaign's goal was a 5 percent reduction in mortality, Baylor reduced risk-adjusted mortality 10.1 percent across the system from July 2004 to June 2006 (fiscal years 2005 and 2006). During the following 12 months, risk-adjusted mortality continued to decline by 11.4 percent.

* Hospital Standardized Mortality Ratio (HSMR) represents the ratio of observed deaths divided by expected deaths across all eight BHCS acute care hospitals. Expected deaths are determined using the State of Texas Public Use Data File for the calendar year 2004 as a normative source of mortality rates for each APR-DRG / Risk of Mortality pair. A value of 1.0 would represent an average outcome for patient care in Texas during 2004. Admissions for all patients are shown in the solid line; the dashed line represents the exclusion of patient admissions that involved formal end of life care (hospice or specialty level palliative care services and live discharges to post-discharge hospice care). (Source: BHCS)

GOOD NEWS: How Hill Physicians Medical Group Partners With Physicians (Part II)

Tom Emswiler — Fri, 27 Mar 2009 15:22:00 -0400

(This continues our blog series on our recent papers on health care quality published by the Commonwealth Fund.)

Hill Physicians Medical Group is an independent practice association in northern California; Len Nichols and I have profiled their work partnering with physicians and improving quality in a just-released case study published by The Commonwealth Fund.

Yesterday, I introduced Hill and the IPA concept, and I talked about how Hill's health educators were able to make quality "stick." Today I'll discuss their compensation strategy.

Hill pays its doctors using an unusual hybrid compensation formula, comprised of fee-for-service (FFS) and its own pay-for-performance reimbursement. Hill receives fixed payments per beneficiary from its health plan partners, and then pays its contracted physicians on a FFS basis. Hill does not pay 100 percent of prevailing FFS rates. Instead, it pays approximately 85 percent. The withheld funds, along with any excess discretionary funds, are deposited into a population management fund, which is dispersed by Hill based on physician performance. That fund is supplemented by the Integrated Healthcare Association (IHA) statewide pay-for-performance (P4P) initiative, but the dollars come mostly from amounts budgeted by Hill Physicians.

Physicians receive population management payments according to a three-part formula, which is recalibrated annually. Currently the formula is: utilization performance, 45 percent; clinical performance, 30 percent (including cancer screenings, diabetes management, childhood immunizations, and management of low back pain); and participation performance: 25 percent (measures their level of involvement with Hill and willingness to implement Hill initiatives).

Eighty-five percent of physicians receive population management fund payments. The remaining physicians either do not meet outcome measures, or they do not have a sufficient number of Hill patients to qualify. For those who do participate, Hill has distributed up to $200,000 per quarter per practice. The amount depends on physician performance, practice size, and the amount of money available in the population management fund each quarter. The average amount is about $20,000 per quarter per practice—$80,000 a year.

While financial incentives alone are not enough to ensure physician behavioral change, small amounts of money are even less likely to motivate improved practice patterns. Hill's population management model provides a significantly greater incentive. The numbers tell the story: in 2006, Hill distributed $32 million in performance compensation to its physicians, yet only $4.4 million of this amount originated from the state's integrated healthcare initiative. Hill found a way to do better.

The most important section of the case study is "Exportable Lessons." I'll summarize three.

Earn doctor trust. Hill found that solving minor problems, paying physicians promptly, and proving its competence at working with the practices engendered confidence and improved communication. Once this trust is built, physicians are more welcoming to organizational initiatives that use physician performance data to highlight areas that need improvement.

Introduce both financial and cultural changes. Money is not the biggest hurdle for most physicians; the problem if often willingness to change. By both earning doctor trust and offering to lessen upfront costs associated with health IT, for example, individuals and practices step forward to change.

Physicians can be managed (usually). By allowing autonomy, but working collaboratively to focus goals and improve care processes and outcomes, Hill has been able to introduce a number of quality improvement tools. Physicians respond to smart management, that is, information, collaborative coaching, and incentives. A well-run organization like Hill Physicians has the ability to streamline administrative processes, enabling physicians to spend more time practicing medicine.

The success of Hill demonstrates that communication, coordination, and feedback are vital to sustainable quality improvement. Their hard work and open-minded approach to care should serve as an inspiration to all those interested in building a health care system that delivers higher value.

Monday I'll be back with a post introducing our case study of the Baylor Health Care System.