Population Health – the (im)precision of language

hospitalNo phrase has less meaning in our industry right now than “Population Health” – this coming from the guy leading his firm’s practice in … wait for it … Population Health.

Everyone has a different picture in their head when those two words leave their mouth, yet that is the industry-standard term nowadays to convey “what comes after fee-for-service (FFS)”.  Here are merely the Top Ten most common meanings in the industry when those words are spoken:

10. Telephoning patients for the purpose of convincing them to consume preventive services

9. Disease Registries embedded in an EMR

8. Convince patients to modify their personal choices (usually via financial-pain or -pleasure)

7. Financial Bonuses to physicians for achieving a numerical score on quality metrics or for following a more complex coding and documentation process

6. Binding together physician practices for the purpose of negotiating higher professional fees (CIN)

5. A software bridge allowing a modicum of data-transfer between different EMRs

4. Buying or building more bricks and mortar to capture more patient care (revenue)

3. Convince patients to undergo biometric testing (patient engagement anyone?)

2. Enforcing the use of Evidence-Based-Protocols for common disease states

1. Providers assuming financial risk or gain for the cost of care provided

Those snapshots represent a small number of available tactics at best, and entirely miss the true meaning of Pop Health at most.  Here’s my definition of Population Health – “the manner in which healthcare design necessarily changes, once it is no longer paid for by piece.”

If the healthcare in question uses FFS as the mechanism for payment, by definition it AIN’T Population Health. The purpose of Population Health is to create higher quality care at lower or similar cost (better care experience, less harm, and more reliably favorable outcomes). In my experience, those better outcomes rarely occur and are never sustained over time, if paid for by FFS, particularly in the absence of group physician practice.

In order for care redesign to be funded and implemented by hospitals and physicians, those providers must be paid for what doesn’t happen: the ER visit avoided because the doc stayed late in the office to diagnose and treat the patient’s UTI; the cardiac cath avoided in the 22 year old with a pulled pectoralis muscle because a history and exam pays the same as cath; an admission avoided because the ambulatory physician did a great job of organizing the patient’s care, such that decompensation never occurred.  Spending time with patients, thinking about them and with them, and coordinating their care all take time, and as we all know, time is money. FFS can only account for what does happen (the ER visit, the admission, the cardiac cath); it’s non sequitur in the context of Population Health.

So the next time you hear the phrase Population Health, ask two questions: (1) “What the hell do you mean by that?”, and (2) “Before we go on, do we agree FFS payment of any type is NOT involved?”

The Triangle of Healthcare Integration

competition, monopoly, economic forcesOversimplification of economic forces can lead to erroneous predictions of market behavior. During the last three years, the mantra within our industry has been “(any) integration of healthcare players will lower healthcare costs and improve clinical and service outcomes.” In fact, we are now seeing the harm that can come from the wrong form of healthcare integration.

monopoly effect upon priceSeveral newspapers (AJC, July 7), consulting firms (personal communication with representatives at Deloitte) and professional societies (ACPE, July 10) are reporting that the craze for physicians to “integrate” with hospitals (typically defined as physicians directly employed by the hospital) is resulting in healthcare prices rising, and substantially so, without value added. This regrettable outcome could have been predicted, and indeed Dr. Michael Doherty, Chief of Staff for our Permanente Medical Group, did so in early 2011. Let’s consider the three ways that physicians, hospitals, and payors can integrate with one another, and the anticipated outcome of each alliance, based upon the interests of the parties involved (modified from Dr. Martin N Gilbert’s insight, June 2013):

#1 Physician & Hospital Integration, without Payor: it’s in both of their economic interests to maximize revenue from the payor(s), who in turn have no choice but to pass on those higher costs to the corporate or public employer.  The physicians and hospital raise prices in the absence of local competition (all physician services and hospital beds are under one geographic, economically-integrated roof). Several examples of this phenomenon exist in Atlanta.

Highmark BCBS#2 Hospital & Payor Integration, without Physicians:  when these two agents team up, unit prices can be driven down (lower prices for hospital beds and professional fees), but physician behavior is unaccounted for, allowing unwarranted high volume of services (overtreatment). One recent example of this type of integration is the Highmark acquisition in western Pennsylvania.

TSPMG logo, standard version, June 2012#3 Payor & Physician Integration, without Hospital:  this form of integration has the most promise to lower costs and improve quality (both players are interested in reducing outpatient overtreatment and improving inpatient efficiencies). This is the KP Georgia model, whereas integrating the Hospital too is the KP California model.

We must create the type of healthcare integration that accounts for the varied economic interests of the various players, if we are to address America’s healthcare crisis in cost and quality. Only integration of payor and physicians, with or without the hospital, will lower costs and raise quality over time.

KP 101: Our Future

healthcare reform

WE BELIEVE … American families deserve lower cost, higher quality, and better service in their healthcare. Given our results (KP 101: Our Results) we can be, and should be, the choice of more Atlanta families and individuals going forward. The federally run Health Insurance Exchange (see www.themarketplace.org) will link more Atlantans to KP, with enrollment beginning October 2013.


WE BELIEVE … healthcare must be more responsive, more holistic, and more timely than in the past. That’s why we are building even more connectivity between patient and doctor, including mobile apps, TeleHealth, and “just-in-time” health information that empowers patients in their decision-making. We’ll be with you everywhere, not just in the exam room or at the bedside.

mol genetics blue gel plate

WE BELIEVE … diagnostic and therapeutic decision-making will become increasingly tailored to the individual, rather than a population of people similar to you. That’s why we’ve invested millions of dollars in research using genomic and predictive-modeling technology intended to create more precise clinical recommendations for patients and families. After all, it’s about you, not them.

couple walking in woods smiling

Kaiser Permanente of Georgia’s future is very bright indeed, given our best-in-Georgia results, our “Care Everywhere” vision, and our tailored approach to your health, not merely your healthcare.


Avoiding the ER

if disney ran your hospital, cover

Despite being in the very human business of relieving pain and suffering, US healthcare is more criticized for its poor customer service than celebrated for its user-friendliness.  For more information, one can begin with “If Disney Ran Your Hospital” (Fred Lee, 2004).

Ms. Jane Brody, the trusted columnist for the New York Times and best-selling author on matters of personal health for nearly 50 years, recently wrote an incisive piece detailing the inadequacy of care-choices after business hours in traditional healthcare (Avoiding Emergency Rooms, April 15, 2013).

jane brody

Ms. Brody hit all the low points of traditional American healthcare … (1) inability to reach the patient’s primary care physician for a simple matter, requiring an ER visit; (2) hours of waiting in the ER before being examined, (3) incomplete testing in the ER, requiring an otherwise unnecessary one-night admission to the hospital, location of super-bacteria and sleep deprivation, and (4) large financial waste.   She concludes “… the medical profession has thus far failed to adequately fill the gap left by doctors who no longer make house calls or answer the phone 24 / 7 / 365”.

TP ACC driveway approach

Well, we have at Kaiser Permanente of Georgia.

This month marks the one year anniversary of the opening of the first of four “Advanced Care Centers” (ACC).  Our ACC effectively addresses each of Ms. Brody’s criticisms: (1) open 24 / 7 / 365, staffed by physicians and nurses with excellent credentials and years of experience in emergency care, who are electronically and telephonically connected to the patient’s physician and her/his partners, (2) prompt and accurate diagnosis and treatment (time from walk-in to walk-out usually less than 2 hours, rather than the 4-6 [or more] in an ER), (3) a full complement of testing capabilities, including lab, imaging, telephonic specialty care AND if needed, quiet, comfortable, sparkling rooms to spend the night in the care of a hospitalist-physician, (4) at a cost lower than an ER copay/visit.  The nearly 2,000 patients per month that use our Kennesaw ACC have been delighted with the quality and service.  The second ACC will open in January 2014 at our Southwood campus in Jonesboro.

ACC room

As Ms. Brody says, “The overuse of emergency rooms is a growing and increasingly costly problem that results in overcrowding, long waits, overly stressed health professionals and compromised care for people with true emergencies”, the latter of which accounts for only 25% or less of patient visits to most ERs.  At KP, we are proud to be The Face of Future Care (see my previous blog post of this title).  TP ACC nurses station

Someone should tell Ms. Brody.

ACA: just the facts

confused childMuch has been written about the full implementation of The Affordable Care Act (ObamaCare) in January 2014, but too little communicated.  Let’s focus on the essential three provisions:

1. Must buy. Most US citizens and legal residents will be required to maintain a level of health insurance coverage for themselves and their dependents, or pay a small financial penalty (a new tax).  The US government will pay none, some, or nearly all of the cost of that insurance, based upon the income level of the individual.

2. Must sell. Health plans (including KP) will be required to accept and renew all individuals wishing to buy, regardless of health status.

italian vegitable market #13. The Marketplace.  A federally run website (also known as the Health Insurance Exchange [HIX]), not unlike amazon.com, will join buyers to sellers.  Insurance Plans with similar benefit packages will have similar names: bronze (covering 60% of healthcare costs), silver (covering 70%), gold (80%) and platinum (90%).  The buyer will choose his/her health coverage from among the various insurance companies, based upon a comparison of price, quality, service and reputation.  The Marketplace goes live October 1, 2013, with coverage beginning January 1, 2014.

In 2014, Small Businesses participating in the HIX will choose one insurance plan for all  employees.  In 2015, each employee may select his-/her-own insurance company to provide the healthcare coverage, within the metal tier selected by the employer.

Clinicians and staff should begin now helping their patients with individual healthcare coverage understand their options coming in October.

Hope that helps.

The Problem to be Solved

I continue to hear physicians in our state rant about ObamaCare, as if the latter is the root cause of healthcare’s ills, rather than merely a symptom (or solution, depending upon your politics).  We humans use our cultural biases and personal experiences to form (correct or incorrect) assumptions about changes in our world, too often failing to deeply understand the root cause of those changes.

I maintain that ObamaCare is NOT the problem to be solved; the Sustainable Growth Rate (SGR) and its offspring, Sequestration, are NOT the problem either; whether Governor Deal will or won’t expand Medicaid in the state – also, NOT the problem for us to solve.  What then?

The root cause of all those symptoms is in fact The Cost of American Healthcare.  That high and rising cost ($8,000 per year for individuals, $12,000 per year for families) is the problem causing the symptoms (2010 ACA legislation, 50% of state budgets used for healthcare, and the 2013 Federal Sequestration).

Here are some more symptoms: (1) employers shifting costs to employees (changes in benefit structure and financing of those benefits), (2) uninsured or underinsured individuals shifting costs to the general economy (see spike in personal bankruptcies due to healthcare bills, the cost of caring for the uninsured or underinsured and the cost of diminished productivity), and (3) the general economy struggling from lower spending in areas other than healthcare (innovation, education, infrastructure, the environment).    Dr. Atul Gawande revealed we physicians are part of the problem (New Yorker, “The Cost Conundrum”, June 2009), and Mr. Steven Brill revealed so are hospitals, pharmaceutical and device manufacturers (Time, “Bitter Pill”, March 2013).

So what’s the sustainable way out?  I see a short list of choices:

  1. Price controls (what Mr. Brill argues)
  2. Mandate all insurers be non-profit, coupled with community rating (our model in the US 1940-1960, and one of two European models today)
  3. Payment reform coupled with a free market (partially underway in the US – see  ACOs)
  4. Rationing of healthcare expenses (see UK or Canada)

What’s your preference?

Putting the Crosshairs on Scope

For years, pharmacists, chiropractors, advanced-practice-nurses, podiatrists, optometrists and so on have fought in the General Assembly of the State Legislature for the expansion of their “Scope of Practice”, referring to the legal lines that define the limits of practice for a given healthcare practitioner, under state licensure.

MAG icon, high-resolution, July 2011For those same years, my beloved state physician association has fought on that same battleground, staunchly opposing such expansion of permissible practice for non-doctors.  This year was no exception.  MAG staff estimates they spend 70% of their year on this sole topic, giving less time to address other pressing matters (health insurance exchanges, payment reform, industry upheaval).

crosshairsPerhaps there is a more efficient way for the professional advocacy groups to spend our time.  Perhaps we can emphasize our common ground and explore root causes of the conflict, then seek a negotiated agreement for the betterment of Georgians and each professional discipline.  Perhaps its time to put the crosshairs on Scope.

Let’s begin with examining root causes of the conflict:

  1. some of the conflict has to do with money: by expanding the limits of practice for non-physicians, the latter can earn more money, at the expense of physician income
  2. some of the conflict has to do with clinical disagreement; podiatrists feel their (no pun intended) sole focus on the feet should empower them to perform more operations on the feet, whereas orthopedic surgeons feel their expansive training and surgical experience is better suited to create an optimal surgical outcome for complex conditions of the feet
  3. some of the conflict has to do with varying assessments of unintended risk to patients; what if, in giving pharmacists the right to administer pediatric vaccinations, kids saw their pediatrician less, leading to missed interventions for scoliosis, developmental delays, sexual health or abuse?

Beyond self-interests, I believe each professional group has altruism in their heart, wishing to improve the health of the communities they serve.  If so, could we agree that any negotiated change in Scope of Practice fulfill two premises:

#1 the proposed change in scope must have sound clinical evidence to support it (see my many previous posts on evidence-based-medicine [EBM]); for example, the requested increase in scope of practice must not only be supported by proof of expanded abilities of the health profession in question, but must also be proved (from a modest clinical trial) to likely “do good and no harm”

#2 the proposed change in scope must be in the public’s best interest (e.g., making low-risk influenza vaccine more accessible to citizens by granting pharmacists the ability to administer them)

team careMAG must maintain its role as the leading voice of Georgia healthcare. The citizens and legislature of Georgia will judge us by our ability to effectively work with, not against, the other healthcare constituencies who deliver care in Georgia.  Let us physicians make the first move to reach agreement on a scope of practice issue that promotes quality, access, affordability and safety with at least one of our healthcare colleagues in pharmacy, nursing, or another field before the 2014 legislative session.

The Face of Future Health Care

Journalist Reed Abelson begins his New York Times article today with “When people talk about the future of health care, Kaiser Permanente is often the model they have in mind.” Let’s examine the ‘why’ and the ‘how’.

We believe better-coordinated patient care leads to more rapid diagnosis, more rapid and effective treatment, through a more humanistic and holistic approach, individually tailored to the person before us. We achieve those superior outcomes first and foremost through (1) a culture of collaboration (highly-reliable team-care, Patient-Centered-Medical-Homes [PCMH]), (2) a culture of safety (best care, best time, best place, no errors), (3) a culture of continuous improvement, powered by (a) sophisticated technology (our exceptional electronic medical record – embedded with the latest best practices; analytics; and performance management systems), as well as (b) physicians and staff who confidently place the interests of the patient before all else.

We believe that physician pay should compensate for long hours of very intense work, devoted to the patient and family, simultaneously devoid of financial incentives of self-enrichment. That’s why our physicians are salaried, rewarded for individual or collective quality achievement, patient satisfaction, and keeping members optimally healthy. Traditional models of healthcare, particularly “fee-for-service” (FFS) models, lead to self-enrichment by maximizing testing, treatment, surgeries and hospitals, often without benefit to the patient (see Atul Gawande’s 2009 New Yorker article, or Steven Brill’s 2013 Time article, among many others).

We believe that physician leadership is a critical component of “re-engineering care” to make it more affordable, more highly satisfying, and more effective, as Mr. Halvorson states in the interview. To do so requires the sensibilities, experience and expertise of physicians. We provide the care in the exam-room, at the bedside, in the OR, after all. Our medical groups are self-governed, making ALL medical decisions with patient and family through a shared-decision-making process. What the Permanente physician establishes as medically necessary for that particular patient gets done, without ANY interference from the insurance end of the business. See my recent editorial in the Atlanta Business Chronicle for more information about the role of physician leadership in redesigning medical care in our country.

We are indeed the face of future health care, AND we have even more re-engineering work to do before we sleep.

The Trouble with Consumerism

Economists speak of two essential premises for a “free market” to exist for a good or service. Among the purchasing options, (1) sellers must provide true choice (e.g., no supplier monopoly) and (2) buyers must possess information (with which to compare the attributes, performance, total cost, and reliability of each choice).


Seldom do those two conditions exist for an individual consumer of healthcare. Her employer has chosen the health plan. His hospital holds a geographic monopoly. Her doctor provides false choices (“We can do [my procedure] or you can continue to suffer.”). A surgeon’s post-operative infection rate or a consultant’s diagnostic accuracy rate is not available. 

Moreover, the majority of the healthcare dollars consumed in the US each year are the result of “acute” (sudden, urgent or emergent) illness or injury.  Can you imagine going through the steps to choose your hospital destination, as you are loaded into the ambulance following a pile-up on the interstate? 

patient preparing to be transfered after MVA

To their credit, American consumers increasingly seek comparative information, particularly on the Internet, but not all Internet content is accurate or applies to the circumstances at hand.  So by and large, individual consumers use lay (rather than medical) advice from friends or family, or “gut feel” to accept or decline a physician’s proposed course of action.

Real choice is coming in the form of Health Insurance Exchanges (HIX), provided for in the 2010 Accountable Care Act (“ObamaCare”). In such a virtual marketplace, individual Georgians will be able to choose Kaiser Permanente when previously that choice was withheld by their employer.

Under such circumstances, it’s best to have a doctor (1) paid to prevent and cure illness, rather than enriched by the magnitude of the patient’s misfortune, (2) judged and challendged by colleagues on the basis of measured quality outcomes, and (3) practicing in a fellowship of altruistically-minded colleagues. Welcome to Permanente medicine and surgery!

tspmg logo, with website Sept 2012