By Mary Agnes Carey

Care management programs, which combine information technology, patient-centered nursing and care coordination, have helped Alliance of Community Health Plan (AHCP) members cut costs and improve patient care, the group said in a report released Wednesday.

For example, the Group Health Cooperative in Seattle has reported more than $2.5 million in cost savings during the first seven months of this year for its 8,224 patients in complex case management and 1,831 patients in regular case management.

Tufts Health Plan in Massachusetts and Rhode Island found that every $1 spent on obstetrical case management for women at high risk for preterm delivery saved $4.50, and on-site and telephone review of hospital utilization saved $4.80 per dollar spent.

The group represents 22 not-for-profit, community-based and regional health plans and provider organizations. The ACHP report says the case management techniques the plans have used included helping patients and caregivers manage medical conditions and psychosocial problems more effectively, coordinating care, reducing duplication of services and reducing the need for expensive medical services.

“Complex, chronically ill patients have traditionally been the most expensive and difficult to treat; almost half of all health care spending in the United States goes to only five percent of patients, many of whom have multiple health conditions as well as social, environmental or financial barriers to good health,” AHCP President and CEO Patricia P. Smith notes in the report. ‘

“Such patients often need and benefit from personalized care, tailored to their individual needs; care management nurses, many of whom work in partnership with social workers, nutritionists, pharmacists and other staff, can step in to supplement the care patients are receiving at their physicians’ offices.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Photo: Steve Woods

By Jordan Rau
This story was produced in collaboration with 

Medicare has begun publishing patient safety ratings for thousands of hospitals as the first step toward paying less to institutions with high rates of surgical complications, infections, mishaps and potentially avoidable deaths.

The new data, available starting last week on Medicare’s Hospital Compare website, evaluate hospitals on how often their patients suffer complications such as a collapsed lung, a blood clot after surgery or an accidental cut or tear during treatment.

The measures also include specific death rates for patients who had breathing problems after surgery, had an operation to repair a weakness in the abdominal aorta or had a treatable complication after an operation.

In addition, Hospital Compare is evaluating rates of some specific medical errors, such as giving patients the wrong type of blood, leaving surgical implements in patients’ bodies during surgery and falls that occur during their stay.

Survey of Patients’ Hospital Experiences

About the survey: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) is a national survey that asks patients about their experiences during a recent hospital stay. Use the results shown here to compare hospitals based on ten important hospital quality topics. Read more information about the survey of patients’ hospital experiences.

The evaluations are part of Medicare’s broad move from paying hospitals a set amount for each procedure. That change was directed by last year’s health care law, which set up new “value-based purchasing program” that will begin in October 2012.

Over time, hospitals with the lowest quality—as judged by a variety of metrics, not just the new patient safety measures—will be at risk to lose up to 2 percent of their regular Medicare reimbursements under the health law.

The new data on patient safety moves Medicare further along toward its ultimate goal, which is to base payments on the actual medical outcomes for patients. To rate hospitals, Medicare is comparing them to the national rates for medical complications and hospital acquired conditions.

For instance, on average, 2.1 out of every 1,000 patients discharged suffered an accidental cut and tear from medical treatment. Out of 100 patients, 4.4 on average died after surgery to repair a weakness in their abdominal aorta.

By looking at how a hospital compares to the national average on this and other complication statistics, Medicare has come up with overall evaluations of how good hospitals are at avoiding complications and hospital-acquired conditions. Medicare is aiming to incorporate the new patient safety data into payments in the second year of the program.

Making this information public has been long favored by patient safety advocates. “This is pulling the curtain back on preventable health care harm to older Americans,” said Rosemary Gibson, co-author of “The Treatment Trap” and editor of a series of articles on overtreatment in the Archives of Internal Medicine. “These are really good things to know. We are really getting into the meat of what can happen to patients in hospitals.”

But the latest data is intensifying objections from the hospital industry and some academic researchers that Medicare is using dubious and unfair measurements in ways that will hurt some hospitals, particularly those with sicker patients. The data is based on billing claims that hospitals submit to the government, not clinical medical records.

One concern held by hospitals and researchers is that hospitals categorize the same things differently when billing Medicare, skewing comparisons.

“Medicare claims data is the thing a lot of people judge from, but it’s a large database and frankly I’ve always wondered if apples and oranges are being mixed,” said Dr. Gerald Healy, a senior fellow at the Institute for Healthcare Improvement, a Massachusetts nonprofit, and past president of the American College of Surgeons.

Hospital officials said their initial review of the new data has exacerbated their concerns that Medicare’s calculations do not fully take into account the fact that some hospitals do more surgeries or treat sicker patients.

“We believe the data is fairly seriously flawed in the way it’s calculated,” said Nancy Foster, a vice president at the American Hospital Association. “When inaccurate data is out there, it both misleads the public and generates a lot of activity that is unproductive in the hospital.”

Atul Grover, head of advocacy for the Association of American Medical Colleges that represents teaching hospitals, said some of Medicare’s measures also make teaching hospitals look worse.

“If you’re not appropriately risk-adjusting on this, you’re already selecting a patient population that’s more likely to die,” he said. “That’s why they come to us, because other people are reluctant to operate on those complex cases.”

Officials at the Agency for Healthcare Research and Quality, which designed many of the measures, referred questions to Medicare. Officials there were not immediately available to discuss the new measures. Dr. Patrick Romano, a professor at the University of California, Davis School of Medicine who helped the government design the measures, said the measures do take the sickness levels of patients into account, although not as thoroughly as Hospital Compare’s existing evaluations of readmissions and hospital-wide mortality rates.

Still, he said the measures were a good addition to the overall view of how well hospitals are doing. “We’re trying to understand a large animal like an elephant or a whale,” he said. “To do that, we take pictures from a variety of perspectives, with different cameras and different techniques.”

Hospital Compare was originally designed to be a helpful consumer tool, but to date it has not been widely used by patients choosing hospitals. Experts caution about drawing dire conclusions from the raw rates of hospitals, as some of the measures are complex and differences not statistically significant.

For some of the measures, Hospital Compare categorizes most hospitals simply as “average,” “above” or “below” the national norm, which experts say is a better way for consumers to know whether a hospital is an outlier.

To find a hospital on the site, type in the city and state, click on the hospital name and then select the “Patient Safety Measures” tab at the left. Hospital Compare also gives patients the option of choosing several hospitals at once. The new data covers the period between October 2008 and June 2010.

Medicare last week also announced 18 more measures it is considering for inclusion in the value-based purchasing program.  Many of these measures look at how hospitals handle stroke patients and what steps they take to protect patients from blood clots. Others are intended to address two bacterial infections that can spread through hospitals: Clostridium difficile and Methicillin-resistant Staphylococcus aureus.

Illustration: Steve Woods Photography

Contact Jordan Rau: jrau@kff.org

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Dr. Eric Larson

By Dr. Eric Larson,
Executive Director of the Group Health Research Institute

Americans are drowning in data while starving for transformational ideas. So writes Neal Gabler in his August 13 New York Times piece, “The Elusive Big Idea.”

Think Albert Einstein’s theory of relativity, Marshall McLuhan’s “medium is the message,” and Betty Friedan’s “feminine mystique.”

Concepts like these let us “get our minds around our existence and attempt to answer the big daunting questions of our lives,” wrote Gabler, of the University of Southern California.

Such visionary ideas could once “ignite fires of debate, incite revolutions, and fundamentally change the way we look at and think about the world.”

I thought about our work and our nation’s struggle with health care costs in a floundering economy. We’ve had 45 years of experiments in health care policy and finance. We’ve spent many billions of public and private dollars on health research. We now have access to unprecedented volumes of data from electronic medical records and health plan information systems.

Nine days after the Gabler piece, Group Health e-mail buzzed with another New York Times article, “Cut Medicare, Help Patients.” Its authors, former White House advisors Drs. Ezekiel Emanuel and Jeffrey Liebman, warned “Medicare is going to be cut…. The only question is whether the cuts will be smart ones.”

They spotlighted providers eliminating waste without harming patient care—and in some cases, actually improving it. One example they hailed: Group Health’s medical home pilot, which boosted quality while reducing emergency visits, hospitalizations, and overall costs.

They cited other instances where providers:

• forego tests, treatment, and procedures that don’t work,

• recommend low-cost alternatives to pricey care that gets comparable outcomes, and

• stop giving care that ultimately causes more harm than good.

So here it is, under our noses—the elusive big idea that might fix American health care—if only our society can embrace it: Less is more.

It’s a simple concept that too few have grasped. Our nation’s dominant fee-for-service health care economy rewards providers for giving more care—not less.

Even in capitated systems like Group Health—where doctors are paid per patient rather than per service provided—community norms may pressure clinicians to do more care than necessary.

Without a major finance overhaul, a call for less care threatens many health worker incomes. Patients also resist change because they tend to trust their providers’ advice; they don’t see the business plan behind the clinician, the incentive to sell more of this test or that procedure to meet margin. Add the political spectacle of candidates equating health reform with “death panels,” and it’s easy to see why many Americans fear substantive reform.

Despite resistance to “less is more,” however, there’s great opportunity for positive change. As Dr. Charles Kilo and I described in the Journal of the American Medical Association (JAMA), current excesses in American health care may actually outweigh its benefits.

Group Health is helping to change this reality through research and innovation. We’re evaluating the effectiveness and costs of various models of care. We’re learning the comparative values of approaches to common problems like back pain, obesity, depression, high blood pressure, and diabetes. We’re exploring ways to help patients take charge of their health behaviors, leading healthier lives that require less—not more—health care.

And rather than drowning in data, as Gabler suggests, our multidisciplinary teams of biostatisticians, epidemiologists, and economists are discovering new methods to harness the power of emerging information resources.

As debates over the federal deficit and health reform continue, Group Health Research Institute is preparing for change.

Traditionally, health institutes like ours have asked, “What else can we do to help people lose weight, prevent cancer, manage chronic illness?” We’ll keep asking such questions.

But it’s become even more imperative to ask, “How can we control costs without harming care?” “In studying treatment, when is less actually more?”

Such questions are sensitive and challenge many fundamental notions about health care. But now is the time to embrace big ideas.

Eric B. Larson, MD is executive director of the Group Health Research Institute. This article first appeared as a “Notes from Eric” column in Group Health Research News.

To learn more:

• Read Neal Gabler’s New York Times article, “The Elusive Big Idea.”

• Read Drs. Ezekiel Emanuel and Jeffrey Liebman’s New York Times article, “Cut Medicare, Help Patients.”

• Read Drs. Eric B. Larson’s and Charles Kilo’s JAMA article, “Exploring the Harmful Effects of Health Care.”

Sara Kasper has been named executive director of Self-Funded Products and Services for Group Health Cooperative.

Kasper works with division leadership to determine the requirements and specifications for product design, provider networks, contract arrangements, medical management, and utilization management to create self-funded plan offerings.

She also works with senior leaders across the enterprise to deploy, grow, and sustain profitable enrollment in self-funded products.

Prior to joining Group Health, Kasper oversaw the strategic direction of all self-funding business process solutions at First Choice Health—from the business systems and processes to customer acquisition and retention.

She has also directed Managed Care Services at PacMed Clinics and served as practice management consultant at California Pacific Medical Organization.

Kasper has a Bachelor of Science in Biology from Washington State University, and completed the Executive Development Program at the University of Washington.

Laura Sandstrom named vice president of Group Health Options, Inc.

Laura Sandstrom has been named vice president of Group Health Options, Inc., the choice plan subsidiary of Group Health Cooperative. She manages performance of Options and Alliant lines of business, and is also part of the Health Plan Division Leadership Team.

Options is a wholly owned subsidiary of Group Health Cooperative. It offers a variety of health plans in Washington that provide choice and flexibility to meet the needs of large and small employers, and in Idaho for large employers.

These range from a defined physician-network plan to point-of-service plans in which members can get care from outside the network for higher out-of-pocket costs.

Before joining Group Health, she was a senior partner at Mercer, and the account executive managing health and benefit consulting services on behalf of The Boeing Company.

Sandstrom has a management certificate from Portland State University, and is a frequent speaker on reengineering and outsourcing administration.

Barbara Trehearne named vice president of clinical excellence, quality, and nursing practice

Barbara Trehearne, PhD, RN has been named vice president of Clinical Excellence, Quality, and Nursing Practice for Group Health Cooperative.

She is responsible for supporting clinical excellence and quality throughout the care delivery system, providing leadership for the development and support of nursing professionals at Group Health, and for Infection Control and Employee Health.

Dr. Trehearne has worked for Group Health for more than 30 years in roles that include nursing education, staff development, and nursing administration.

She is also an associate dean of clinical practice at the University of Washington School of Nursing.

She is a graduate of Riverside White Cross School of Nursing, holds bachelor’s of science and master’s of science degrees from Ohio State University, and completed her PhD from the Union Institute in Ohio in 2001.

Dr. Trehearne is currently chair of the Washington Center for Nursing’s board of directors, a fellow in the Western Academy of Nursing and the Center for Nursing Leadership, and a member of numerous nursing associations.

Honors she’s received include the Distinguished Career award from the Northwest Organization of Nursing Executives, and the Mountain West Region Nursing Excellence Award for Advancing and Leading the Profession.

Cindy Johnson named executive vice president of Human Resources

Cindy Johnson has been named executive vice president of Human Resources for Group Health Cooperative.

Cindy is responsible for developing key human resources initiatives that support and link with the strategic plan and vision of the organization.

Prior to joining Group Health in 2006 as vice president of Human Resources, Johnson was the vice president of Human Resources for Stanford University Hospital & Clinics and Lucile Salter Packard Children’s Hospital in Palo Alto, CA. She has held varying leadership positions at Evergreen Healthcare in Kirkland, WA, and at the University of Washington.

Johnson holds Strategic Human Resource Management certification from Harvard Business School Executive Education and is a fellow with the College of Healthcare Executives. She received her bachelor’s in education from Western Washington University.

Robert Reid named associate medical director of health services research & knowledge translation

Robert Reid, MD, PhD, has been named associate medical director of Health Services Research & Knowledge Translation for Group Health Cooperative.

He is also associate investigator at Group Health Research Institute (GHRI), and a preventive medicine physician.

Dr. Reid’s research interests include primary care organization, financing and design, and the translation of health services research into day-to-day clinical practice and management.

At the Institute, he’s responsible for working with Group Health leaders to identify strategic knowledge gaps and research opportunities, promoting a culture of rapid learning, and bringing leading edge science into the organization.

He also advises on the design, implementation, evaluation, and dissemination of health services and systems innovations at Group Health.

Dr. Reid has a PhD in health policy and management and a master’s of public health in epidemiology from Johns Hopkins Bloomberg School of Public Health, and an MD from theUniversity of Alberta.

He is a member of the American College of Medical Quality, and a fellow at the American College of Preventive Medicine

 The free mobile app includes five key health features:

• Mobile access to medical records (including the ability to check test results, view visit summaries, check immunization histories and more),

• Direct access to call or secure message a consulting nurse 24/7,

• Maps to the nearest Group Health Medical Centers,

• Comprehensive symptom checker.

A future update under consideration is access to proxy health files, including a child’s immunization records.

Currently, the Group Health mobile app is available for iPhones in the app store. Development is underway to launch an Android version of the mobile app later this year, the health plan said.

To download the new app go here.