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The CEO Checklist For Better Medical Care

(IOM -- The CEO Checklist)

Checklists are all the rage in medicine these days.

The simple concept — that a short, well-crafted list of basic but critical items can help focus even the most accomplished doctor and improve care — was pioneered by Dr. Peter Pronovost, of Johns Hopkins and popularized by Dr. Atul Gawande, the New Yorker writer and surgeon at Brigham & Women’s Hospital. Gawande wrote about checklists for surgery, among others. And recently, a study came out on an effective, World Health Organization-backed checklist for childbirth.

Today, the Institute of Medicine releases a new paper: A CEO Checklist for High-Value Care , written by 11 hospital chiefs, among them Gary Gottlieb, the president and CEO of Partners HealthCare System, Inc.

But a surgical checklist, which includes things like identifying the patient and surgical site and making sure all the sponges are accounted for after an operation, may be simpler and more practical then establishing a “culture of continuous improvement — commitment to ongoing, real-time learning,” which is #2 on the CEO’s Checklist.

Indeed the IOM paper notes: “The strategies in this Checklist are not, of course, of the “one-and-done” variety. Rather, the items we present here are elements that must become core components of an organization’s DNA.”

But if an institution’s DNA actually does evolve, care improves, according to these CEOs, and costs decline as certain wasteful practices are eliminated.

For instance, the paper notes two examples involving Partners:

1. Partners HealthCare’s Connected Cardiac Care Program (CCCP) is a home monitoring program for heart failure (HF) patients at risk for hospitalization. CCCP’s core components are care coordination, education, and development of self- management skills through the use of telemonitoring. Patients use home monitoring equipment to submit weight, blood pressure, heart rate, and symptoms on a daily basis.
• Better care: 51 percent reduction in HF hospital readmission; 44 percent reduction in non-HF hospital readmission
• Lower costs: More than $10 million in savings to date ($8,155 per patient)

2. Partners participated in a 3-year demonstration project to test strategies to improve the coordination of high-cost Medicare patients. To help primary care physicians manage these patients, case managers were integrated into primary care practices. Case managers developed personal relationships with enrolled patients and worked closely with physicians to help identify gaps in patient care, coordinate providers and services, facilitate communication (especially during transitions), and help educate patients and providers.
• Better care: 20 percent reduction in admissions; 13 percent reduction in ED visits
• Lower costs: $2.65 saved for every $1 spent; 7 percent net savings for each patient in the program

Paul Levy ‘Does The Math,’ Says New Partners Contracts Increase Disparity

Paul Levy of "Not Running A Hospital"

WBUR’s Martha Bebinger had a couple of follow-up questions for Paul Levy, former chief of Beth Israel Deaconess Medical Center and still a widely read blogger who, among a great many other topics, regularly takes Partners HealthCare to task for its high prices.

One of his latest posts discusses Partners’ recent renegotiation of its contracts with Blue Cross and Tufts Health Plan, touted in press releases as saving tens of millions of dollars. He writes that the new contracts will only increase the disparity between Partners’ prices and everyone else’s, and he calculates that over the last decade, Partners has added roughly $2 billion to health care costs paid by Massachusetts businesses and individuals.

Martha asked via email:

1)Why would the disparity between Partners HealthCare System rates and other providers increase under this contract?

2)How do you get the $2 billion figure?

And Paul Levy replied:

Simple math, Martha. Everyone else is getting rate increases of, at most, the same 2-3 percent. Many are getting below that. Since the base for the others was lower than PHS, the spread between the PHS rates and theirs has to be growing. Continue reading

Tufts Health Plan And Partners Renegotiate, Estimate $105M In Savings

Partners: Rethinking care delivery to control costs

WBUR’s Martha Bebinger reports:

The state’s largest hospital network, Partners Health Care, has signed a second contract that trims health care spending. A deal out today with Tufts Health Plan is expected to reduce payments over four years by $105 million dollars: Partners opened an existing contract with Tufts to re-negotiated a lower payment rate.

For Tufts members that means roughly 1% off premium increase they might otherwise see.

Partners CEO Gary Gotlieb says Partners doctors and hospitals realize that rising health care costs are a burden on families, businesses and the government.

“We have to be responsible in looking at that and therefore, we’ll rip up those contracts and look for ways that we can take increases that are smaller over this period of time,” Gottlieb said.

Last year, Partners, which owns Massachusetts General and Brigham and Women’s hospital, agreed to a contract with Blue Cross Blue Shield of Massachusetts, the state’s largest insurer, that will save $240 million. Partners says it is doing its part to relieve the pressure of rising health care costs.

Tufts Health Plan CEO Jim Roosevelt says Partners will also move to a so-called global payment system based on keeping people healthy, not just how many services doctors provide. Continue reading

What Boston’s Pioneer ACOs Will Mean For Patients


As we reported last week, five Boston area hospitals and physician groups will have a dominant role in a federal experiment that could transform Medicare. All Medicare patients who see doctors through Atrius Health, Partners HealthCare, Beth Israel Deaconess Medical Center, Mount Auburn Hospital or any of the Steward Health hospitals will be affected.  The question is how?

The Centers for Medicare and Medicaid Services (CMS) today announced 32 organizations that will “Pioneer” the move to accountable care organizations (ACOs). Greater Boston, with five of the 32, will have a large concentration of doctors and patients testing ways to coordinate care and reduce costs.

Medicare rules become the standard for payments and care at most hospitals.  So when these major groups in Boston start doing more preventive care or requiring more interaction among all a Medicare patient’s doctors, the same practices will likely apply — eventually — to patients of all ages.

This pilot will not restrict where patients go for care. Hospitals and doctors will be rewarded for beating their prior spending thresholds and for showing patient care improvements. These groups could lose money if patients need more care than they have in the past or if they get a lot of expensive care that isn’t coordinated.

CMS says this experiment could save $1.1 billion over the next five years.  That’s a lot of money, but keep in mind that the Medicare budget this year is $468 billion.

We asked leaders of each Boston area organization to answer this question: How will joining this pilot project affect the way you care for Medicare patients? Continue reading

Will Health Reform Finally Push Doctors To Email And Skype?

Dr. Lester Hartman as seen via Skype

No one could blame 3-year-old Anish for getting hysterical when he saw a doctor. He’d been through open-heart surgery and a skull operation. He knew that white coats often meant pain.

The first time his mother brought him to see Dr. Lester Hartman of Westwood-Mansfield Pediatric Associates, he had such a meltdown in the office that the visit had to take place in the parking lot, with the engine running, Anish in his carseat, and the pediatrician leaning his laptop on the driver’s side window as he took notes.

Clearly, this was not going to work. So these days, unless Anish needs to be physically seen, his parents schedule their appointments for evening hours. They sit at their home computer and they consult with Dr. Hartman, face to face, but not in person — by Skype.

Those Skype visits put Dr. Hartman way far out on the cutting edge of using technology to communicate with patients, even though Skype is now very old news in the general population. But he has high hopes that if health reform plays out as expected in Massachusetts, he’ll be able to ramp up Skype and use other electronic tools more creatively in his practice. (See his guest post below.)

‘Why hasn’t it gone further faster?’

Health care lags dramatically — perhaps “pathetically” is the correct adverb — behind other sectors in the use of the technological tools that now tend to dominate our personal lives — email, Skype, Facebook, smartphones. As Dr. Ronald Dixon of Massachusetts General Hospital put it: “Our patients are all Skyping with their grandchildren, so why can’t they Skype with us?”

But multiplying signals suggest that early adopters like Dr. Hartman may soon get a major boost from a political source: The looming state health reform. It aims to save money by shifting care away from “fee-for-service” payments for each procedure and toward giving doctors a “global” budget for a patient’s annual care.

Health insurers do not generally reimburse doctors for time spent emailing or Skyping or texting. When a doctor is paid for each bit of in-person care, but not for such “virtual” care, that’s a major disincentive to go virtual. On the other hand, if a doctor is paid an overarching annual sum for your care and will get bonuses for keeping you healthier and within your budget, checking in with you by email or Skype may suddenly become much more attractive.

Dr. Joseph Kvedar, director of the Center for Connected Health at Partners Healthcare and a practicing dermatologist, says that under the current health-care payment system, he emails constantly with his patients for free just because he sees it as part of caring for them. But “If the cash register never rang, I wouldn’t have a job. Right now, if you stop coming in to the office, I have a real problem. That won’t be the case anymore two years from now. The time is upon us that it will be as quaint as bank tellers.” Continue reading

Partners CEO: A ‘Sentinel Moment’ In Health Reform?

Partners CEO Dr. Gary Gottlieb

(For related news stories, see WBUR here — Blue Cross, Partners Finalize Deal To Slow Premium Hikes — and the Boston Globe here.)

If I were writing the rough draft of current Massachusetts health reform history, this would be my intro:

On Oct. 5, 2011, it became clearer than ever that Massachusetts would indeed march forward toward payment reform, moving away from traditional “fee for service” and toward giving doctors annual budgets for a patient’s overall care.

Whatever now happened in the political arena, the reality on the ground was already shifting dramatically. On Oct. 5, Partners HealthCare — the state’s largest hospital system and largest employer overall — officially announced that it would enter a global payment plan offered by Blue Cross. The behemoth of Massachusetts medicine was throwing its tremendous weight and resources behind the move toward global payments. What had been a growing scatter of promising experiments was now going ever more mainstream.

Rough drafts of history aside, and though only about 200,000 patients will be initially affected, I do have the feeling that this is a significant moment in health reform, locally and perhaps nationally, too. How did this come to be? I asked Partners CEO Dr. Gary Gottlieb. His reply, slightly condensed:

There are two elements. One is that, as we’ve told you, we’ve been working on our strategy since I started, and that has focused on both care redesign and population management. And an essential part of population management is managing high-risk populations.

We believe that in order for health care to be redesigned in a way that is patient- and family-centered, we need to move away from transactional fee for service, and sharing risk with a payer provides the opportunity to use resources more effectively.

‘Do I think Partners’ moving into this is a sentinel moment?’

It has the potential to be able to focus on individual patient needs and to design care in a way that moves away from transactional and disorganized care. And the AQC [The Blue Cross global payment plan] is the first opportunity in that regard.

We need payment mechanisms that are consistent with the appropriate redesign of patient and family-centered, efficient care. Whether it’s patient-centered ‘medical homes,’ in which we’ll manage a substantial amount of population risk — or bundled payments, in which there will be episode payments where we can share the risk with specialists…The more flexibility we have in the way we’re paid, the more we’ll be able to achieve these goals.

So, I asked, would it be correct to say that as you looked at how to contain costs, you came to the inescapable conclusion that the modes of payment had to change in order to cut costs? Continue reading

Partners Renegotiates Blue Cross Contract, Joins Global Payment Plan For Cost Cutting

Here’s the press release from Partners:

Partners HealthCare today announced that it has reached an agreement with Blue Cross Blue Shield of Massachusetts that will reduce the growth in health care spending by nearly a quarter of a billion dollars over the next three years. The agreement is a renegotiation of an existing contract and achieves three major objectives:

Partners and BCBS are reducing the amount that Partners would have received by $80 million in 2012. Over the life of the three-year contract, this translates into about $240 million in total savings.

Partners is entering into global payments and taking on risk, as recommended by the Special Commission on Payment Reform. By entering into BCBS’ Alternative Quality Contract, Partners will be required to meet or exceed quality measures for its patients and Partners will be required to keep cost growth lower than the network average for the rest of the BCBS provider network.Rate increases during the contract period will be held in line with general inflation. Continue reading

Video: Use Smartphone Feedback To Get Healthier

As director of Partners HealthCare’s Center for Connected Health, Dr. Joseph C. Kvedar works on breaking down the barriers created by the idea that “you have to visit someone in a physical location to get health care services.”

More on that soon — and on how health reform will help spur that momentum. For now, Joe kindly answers a basic question: Right this moment, with current technology and the current health care system, how can we best use our smartphones to get healthier?

There are scads of health-related apps on the market, but Joe boils down his advice to under three minutes and begins with this: “Probably the simplest thing we can all do is track activity,” and smart pedometers these days can send our numbers of steps wirelessly to phones or Websites for easy graphing and reminders. Technophile readers, any recommendations?

New Partners Option Aims To Keep Employees In-House For Care

Partners: Rethinking care delivery to control costs


Partners HealthCare, the state’s largest employer, is in the process of notifying its 60,000-plus employees of a new option in their health insurance: a plan that charges them more out-of-pocket for non-Partners care.

The plan would begin Jan. 1. A notice that already went out at one Partners hospital explains, “We want to encourage employees and their families to receive their health care from providers within the Partners HealthCare System.”

Now, this is nothing new, for a hospital network to aim to keep employees in-house for care. But when Partners does it, it raises an obvious question: Partners — which includes Massachusetts General Hospital and Brigham and Women’s Hospital, as well as community hospitals and health centers — has repeatedly been cited by state authorities as a key driver of high medical costs. If more people from among its multitudinous employees get care at Partners, won’t that drive costs still higher?

The notice addresses that issue:

Why We’re Making Changes
Numerous surveys confirm that Partners has the best providers not only in Massachusetts, but nationwide. We want our employees to benefit from Partners’ world-class care while paying the lowest possible cost. It is often reported that care at Partners facilities costs more. However, Partners’ higher unit costs are significantly offset by greater value and better quality care through fewer visits and better outcomes.

Encouraging our employees and their families to receive care from Partners providers not only benefits our employees, but also will help us meet future financial challenges by broadening our patient base.

Readers, thoughts? My own initial reaction: Health insurers have been creating plans that use financial incentives to push patients away from higher-cost providers like Partners. Is this the counter-push?

More details from the notice: Continue reading

Breaking: Steward Launches Health Insurance

WBUR's Martha Bebinger


This just in from WBUR’s Martha Bebinger:

Steward, the state’s second largest hospital network, is launching a health insurance plan that will attract attention on price.

Steward says its plan will cost 20 to 30% less than coverage offered by other health insurers in Massachusetts. Members will be limited to doctors and hospitals in the Steward network unless they need highly specialized treatment. In that case, Steward will send patients to competitor hospitals, Brigham and Women’s or Mass General. Children will be able to see pediatricians affiliated with Partners Health Care

The Steward coverage is offered through Tufts Health Plan. This move will help Steward fill its growing network of hospitals and get ready for the move to global payments under which doctors and hospitals manage budgets for their patients’ care. Steward CEO Ralph de la Torre is scheduled to outline his plans to the state’s largest employer group, Associated Industries of Massachusetts, this morning.

Related: Today’s column from the Globe’s Steve Syre is headlined “Hospitals’ Cost Gamble” and ends:

The next step: Big medical groups developing their own coverage plans, limiting care mostly to their hospitals and doctors.

Steward – which emphasizes the lower cost of its network – has offered a plan like that to employees for a few years and now covers about 8,000 patients. I’m sure it would love to turn that plan into a commercial product sold by insurance companies (Steward chief Ralph de la Torre will speak this morning before the Associated Industries of Massachusetts. I wonder if it will come up in the conversation.).

One way or another, efforts to control medical costs will continue to shift financial risks to health care providers. That means doctors and hospitals will have to think more like insurers.