St. Mary’s Hospital in Apple Valley has been working on a very important problem for the community. Emergency room visits have more than doubled from 30,000 per year to near 80,000 per year in only 5 years. Utilizing the tools and principles of the lean journey for the last 3 years they have been able to free up 30% more capacity in the E.R. and have reduced the time patients wait to be admitted from the E.R. to the inpatient unit by 300% which has allowed them to see all these new visits without any significant new capital expenditure.This is just one of the impressive improvements they have made since beginning to learn the lean way,in fact they call it the St. Mary’s Way and it involves their front line staff redesigning and improving the processes of care delivery.
About an hour to the south St. Joseph’s Hospital of Orange Co.has done similar work in the E.R. and although the volume hasn’t increased as much as St. Mary’s, in the last year they have seen 9% more patients in one of the busiest ERs in California (118,000 visits /yr) without adding staff or building any new capacity.
What kind of magic is going on at St. Joseph’s health system? Of course, it isn’t magic at all. The leaders at St. Joe’s are dedicated to 2 things: respect for people and continuous improvement. They have done a lot of work to create a culture of respect including a great employee recognition program and developing an environment where staff are encouraged to suggest ideas for improvement. This is accomplished through a management team that espouses being humble and respectful of each other and their staff. When the tools of lean are added to these key cultural components remarkable things can happen as evidenced by the above.
This is not to say St. Joe’s is done or has achieved all they can or want to.To the contrary, they are humble enough to realize in many ways they have just begun but because they have the fundamentals of lean in place and the leadership commitment is strong they will continue to improve care for their patients forever. Congratulations to the staff, managers, and physicians at St. Joseph and St. Mary’s Hospitals.
This article in the WSJ shows how far we have to go to change the way we think about improving healthcare in the U.S. The following are some quotes from the article and my comments. Read the whole article at the end of my blog.
“I am an ear/nose/throat specialist. Maybe 40% of my referrals were initially misdiagnosed” This editorial has shame and blame plastered all over it. The blaming of the doctors who refer him patients but no recognition of the thousands of patients that primary care doctors have treated appropriately and therefore,never got to him. Is his data accurate? “maybe 40%”, has he ever measured this or it just a gut thing?When I practiced medicine I thought I did a wonderful job of controlling cholesterol levels in my patients with heart disease until I actually pulled out the charts on each of them and found only 26% were meeting goal.Once I had the data I worked hard to improve the result to 80% meeting goal in six months. I used something called a protocol which this doctor says is cookbook medicine.If I were the patient give me the cookbook please.
“As a specialist, I have better equipment to diagnose illness. I have better cure rates than others because I am able to actually see what is wrong with patients using in-office fiberoptic cameras, CT scans and audiologic testing. I can use these test results, along with elements of the patient’s history, to show the patient that his ear pain is temporomandibular joint disease and not an infection, that his sinus problem is actually migraine, and that his throat infection is a manifestation of reflux. I can spend more time with patients because I can charge for these tests”. Wow,spend more time with patients because he can charge for tests? That presumes if he didn’t charge for tests he wouldn’t spend much if any time with patients. what about better cure rates? Compared to whom? Where can I access this data? I want to go to the doctor with best cure rates,what diagnosis is he talking about? How many patients has he seen with these diagnosis and how does he know his cure rates are better than any other ENT specialist or for that matter better than the primary doctors he claims send him inaccurately diagnosed patients?
“I challenge you to tell me that I am more expensive in the long run than weeks or months of inappropriate treatment for incorrect diagnoses”. I would only know if you were more expensive if I could compare a series of claims data on each patient you care for by specific diagnosis. In Wisconsin because of the data base created by The Wisconsin Health Information organization we could tell you how you compare to other doctors managing the same episode of care.But at the moment, in Georgia, there is no data base like Wisconsin and therefore it is pure speculation his care is more cost effective.
“I am successful because of the market forces which Dr. Berwick condescendingly dismisses. Medicine is truly an art. Dr. Berwick’s ideal health-care system will only replace our current rationing of health care from those who have insurance and money, to rationing by government bureaucracy”. As you can read on this site I am a big fan of market forces driving better healthcare value. I am also a major proponent of improving the process of care because medicine is far from purely an art. Most processes by which we deliver care are broken as evidenced by the 100 million medication errors which occur each year in the U.S.as well as many the other errors. We address both market forces and process improvement in detail in our recently published book “On the Mend”.
The author’s final conclusion is also flawed.He suggests that Berwick’s going to ration healthcare. That’s simply wrong. Berwick is one of the nation’s true experts in quality improvement and clearly understands that removing waste and improving quality is the way to reduce cost. If healthcare providers could actually become engaged in improvement we would never need to ration anything. So if we’d just let Berwick do his job the country’s journey of healthcare improvement could begin and we would begin to see better cost and quality across the industry.
Let’s stop the shame and blame,start basing our comments on data rather opinion and get this country focused on reducing unnecessary utilization improving inefficiency and creating a better patient
To read the article, click here – http://online.wsj.com/article/SB10001424052748704913304575371210975895460.html
I have blogged on many occasions regarding the fact that Congress solved for the wrong problem enacting health reform. The problem is the exponential rate of cost increases of American Healthcare. This is the same problem plaguing other countries such as France Germany and the U.K. So it is not just an American but a universal problem which if not addressed will lead to devastating effects on the world economy.
In their article the authors suggest that Massachusetts and Tennessee provide recent examples of cases where insurance coverage expansion has led to cost increases instead of savings. Tennessee had to scrap it’s plan after costs tripled from $2.5 billion in 1995 to $8 billion in 2004.In Massachusetts the authors describe, “the Special Commission on Health Care Payment System has produced payment recommendations in the wake of passing an individual insurance mandate and coverage expansions. But the commissions’ recommendations have not yet been enacted into law,so overall costs,which are growing 8 percent a year in Massachusetts,have not slowed”. And that’s the point, the exponential growth in cost is not slowing in Massachusetts and will not slow nationally either.
“What is the bottom Line? Removing the potentially unrealistic annual savings,reflecting the full costs of implementing the programs,acknowledging the unlikelihood of raising all of the promised revenues,and preserving premiums for the programs they are intended to finance produces a radically different bottom line. The act generates additional deficits of $562 billion in the first 10 years. And because the nation would be on the hook for two more entitlement programs rapidly expanding as far as the eye can see,the deficit in second ten years would approach $1.5 trillion”.
I’ve also said on these pages I’m all for covering all Americans with health insurance but not at the expense of further devastation of our economy. The only way out is to address the cost and quality problems in American healthcare and although there are some programs in the health reform legislation that attempt to address these issues it will be years in piloting and studying and publishing before anything sticks.We need to change the delivery of care now not in ten years. We have great examples published on these pages and elsewhere of where radical changes are happening and how they are being implemented. Real reform will only happen when the government wakes up to this fact and moves in the direction to support this activity, by paying differently and releasing the Medicare administrative claims data so we create comparative performance data across all health systems.
This article in the New York Times shows that politicians can make anyone,even Don Berwick into a villain.
This article casts Don Berwick as an inhumane healthcare rationing freak.We all know this is just political wrangling having nothing to do with the truth.Despite all the letters we have written in support of Don Berwick the senators aren’t listening.
I’d suggest another barrage of letters this time focused on Mr. Grassley and a few others.They need to clearly understand the healthcare providers in the country listen and respect Dr. Berwick and believe him to be the best choice for CMS director.
NY TIMES: Confirmation Fight on Health Chief
WASHINGTON — President Obama’s nominee to run Medicare and Medicaid, Dr. Donald M. Berwick, is a man with a mission, a preacher and a teacher who has been showing hospitals how they can save lives and money by zealously adhering to clinical protocols for the treatment of patients.
Hospital executives who have worked with Dr. Berwick describe him as a visionary, inspiring leader.
But a battle has erupted over his nomination, suggesting that Dr. Berwick faces a long uphill struggle to win Senate confirmation.
Republicans are using the nomination to revive their arguments against the new health care law, which they see as a potent issue in this fall’s elections, and Dr. Berwick has given them plenty of ammunition.
In two decades as a professor of health policy and as a prolific writer, he has spoken of the need to ration health care and cap spending and has confessed to a love affair with the British health care system. He has made numerous public appearances to talk about health care and has published a book of his speeches on the topic.
Mr. Obama nominated Dr. Berwick on April 19 to be administrator of the Centers for Medicare and Medicaid Services, the largest purchaser of health care in the United States. The post has been vacant since October 2006, and the need to fill it has become more pressing with passage of the new law. The agency must write and enforce dozens of regulations to expand Medicaid, trim Medicare and test new ways to deliver care.
The Senate Republican leader, Mitch McConnell of Kentucky, describes Dr. Berwick as an “expert on rationing.” Senator Pat Roberts, Republican of Kansas, calls him “the perfect nominee for a president whose aim has always been to save money by rationing health care.”
Dr. Berwick, a pediatrician, is president and co-founder of the Institute for Healthcare Improvement, a not-for-profit organization in Cambridge, Mass.
In an introduction to Dr. Berwick’s book, Dr. Frank Davidoff, a former editor of the Annals of Internal Medicine who works for the institute part time, said, “Don Berwick preaches revolution.”
He is trying to overthrow “a stupid system” that serves the needs of doctors, administrators and insurers rather than patients, Dr. Davidoff said.
Administration officials say they are confident that Dr. Berwick will be confirmed, and they say Republicans have taken his comments out of context. In fact, many of the comments have been repeated, with slight variations, in Dr. Berwick’s articles and lectures over the years.
In an interview last year in the journal Biotechnology Healthcare, Dr. Berwick said, “The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.”
Asked about such statements, Reid H. Cherlin, a White House spokesman, said: “Rationing is rampant in the system today, as insurers make arbitrary decisions about who can get the care they need. Don Berwick wants to see a system in which those decisions are transparent, and the people who make them are held accountable.”
In his book, “Escape Fire: Designs for the Future of Health Care,” Dr. Berwick sharply criticized “the dangerous, toxic and expensive assumption that more is better.” He insists that the nation can cut health costs without harming patients because vast sums are misspent.
“I have said before, and I’ll stand behind it, that the waste level in American medicine approaches 50 percent,” he said in an interview in the journal Health Affairs in 2005.
Dr. Berwick has championed efforts to “reduce the total supply of high-technology medical and surgical care” and to consolidate services in regional centers.
Long before the uproar over “death panels” last year, Dr. Berwick was urging health care providers to “reduce the use of unwanted and ineffective medical procedures at the end of life.”
“Using unwanted procedures in terminal illness is a form of assault,” he said in 1993 at the annual conference of his institute. “In economic terms, it is waste.”
On more than one occasion, Dr. Berwick has suggested a need for a cap on total health spending, with limits on annual increases.
In speeches and articles celebrating the 60th anniversary of Britain’s National Health Service in 2008, Dr. Berwick said he was “in love with the N.H.S.” and explained why it was “such a seductress.”
“The N.H.S. is not just a national treasure,” he wrote; “it is a global treasure.” Among its virtues, he told a British audience, is that “you cap your health care budget.” Instead of trying to protect the wealthy, Dr. Berwick wrote, the British recognized that “sick people tend to be poorer and that poor people tend to be sicker, and that any health care funding plan that is just must redistribute wealth.”
Dr. Berwick offered a suggestion to the British: “Please don’t put your faith in market forces.”
“In the United States,” he wrote, “competition is a major reason for our duplicative, supply-driven, fragmented care system.”
Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee, said he had no doubts about Dr. Berwick’s academic and professional qualifications, but wanted him to explain his comments on rationing.
“It doesn’t help him to say good things about the British health care system,” Mr. Grassley said after meeting with Dr. Berwick on Wednesday. Whatever doubts might exist in Washington, Dr. Berwick has fans in hospitals around the country.
Theodore E. Townsend, president of St. Luke’s Hospital in Cedar Rapids, Iowa, said: “Dr. Berwick has inspired me and this community. He has used his charisma and his leadership ability to improve the quality of care at hundreds and hundreds of hospitals. I can’t think of anyone else who has had that kind of impact.”
Donna C. Isgett, senior vice president of McLeod Health in Florence, S.C., said Dr. Berwick had been “instrumental in catapulting us to a much higher level of care.”
“He rolled up his sleeves and worked with our employees to reduce medication errors, infections, accidental falls and mortality rates,” Ms. Isgett said. “We are not a prestigious institution in Boston. We serve rural counties in one of the poorest regions of the country, but Don has been here and knows us.”
CMS released new information about ACOs this week which will allow patients to choose whether they get all of their care from one ACO or multiple ones.This is an important clarification as it may make it even more difficult to track which part of the provider system gets paid for what.
CMS Issues First Clarification of Accountable Care Organizations
CMS recently offered the first glimpse into what accountable care organizations (ACOs) will look like in the form of a document with preliminary questions and answers about ACOs. Though much still remains to be worked out, CMS is now telling us that ACOs will be required to assume responsibility for a minimum of 5,000 Medicare beneficiaries and will receive financial rewards for improving quality and reducing costs for those beneficiaries.
The biggest new information in the CMS document is that ACOs will not be allowed to restrict the access of Medicare beneficiaries to physicians, hospitals, or any other providers. In other words, ACOs will not be allowed to utilize gate keeper or restricted network strategies. The most likely reason CMS has made this determination is that a scared and angry citizenry is already afraid that healthcare reform will limit their access to providers and benefits, so CMS is going on public record saying that ACOs, a major element in the recently passed healthcare reform bill, will not be able to do so.
CMS to Host June 24 Call on Medicare Accountable Care Organizations
The Centers for Medicare & Medicaid Services will host a conference call June 24 to solicit comments from hospitals and physicians on implementing Medicare accountable care organizations under the health reform law’s Shared Savings Program. Among other topics, CMS seeks input on: joint accountability among providers in the formation and use of ACOs; cost and quality measures to assess performance; risk adjustment; attribution of Medicare beneficiaries to ACOs; benchmarks for defining shared savings; coordination with other value-based purchasing initiatives; and Medicare beneficiary protections.
The following slides show the timeline for the components of the delivery reform portion of the healthcare bill and how it is proposed it will be funded.
The first of the attached slides shows what provider systems should expect from the health reform bill over the next 10 years.The second slide shows how it will be paid for. As you can see the bill will paid for by reducing revenues to hospitals and other providers,reducing payments to Medicare Advantage health plans, as well as increasing Medicare taxes and other taxes on certain industry suppliers such as device makers.
The budget neutrality of the healthcare reform bill assumes that the sustainable growth (SGR) rate reduction for physician payments be implemented each year for the life of the legislation. For example physician payments from Medicare were supposed to go down 21% today but the senate voted in favor of repealing this reduction for 6 more months. If the SGR continues to be repealed over the next 10 years it will add over 200 billion dollars of cost to healthcare. I think we can safely say that is highly likely. I think we can also say it is highly unlikely the proposals to pay for the healthcare bill are going to be budget neutral. This most likely means even further payment cuts to hospitals and other providers of care.
These realities make it even more important for healthcare leadership teams to develop a game plan to remove waste and reduce the cost of delivering care. We encourage you to join the Healthcare Value Leaders Network where learning from those committed to the lean transformation journey continues to show remarkable cost and quality improvements are possible.
Implementation guideline
Payment for bill
