Heartland Health Research Institute Archives | Page 2 of 4

Time to Move Upstream and ‘Invest’ in our Health

Posted on: 11.21.16 By: David P. Lind

Authors: David P. Lind and Yogesh Shah, MD, MPH

Employer-sponsored health premiums in Iowa have increased 215 percent since 1999. This growth, however, appears tame when compared to health insurance plans sold in the individual market. We’ve grown so accustomed to rising health costs that it has become the ‘new normal’ with no apparent silver bullet in sight to remedy the core problems. Healthcare costs continue to outpace general inflation, typically by two-to-three fold. We live with constant anxiety about paying more for our healthcare – whether through taxes, premiums, deductibles and/or other out-of-pocket expenditures.

With the advent of a new Trump administration geared to repeal many Obamacare components, all sorts of health insurance “solutions” will be debated. Ideas to make coverage more competitive include selling policies across state lines, pushing for health savings accounts, and relying on other tax incentives to perform magic. However well-intentioned, belief that the insurance component will somehow fix our cost problem is wishful thinking.

The major source of this problem is our unhealthy population. “Upstream” environmental factors greatly impact our “downstream” health. for all of us. Upstream factors are many – primarily poor nutrition, inadequate housing and education, and low incomes – all considered to be social determinants of our health.

To meaningfully address healthcare costs in Iowa and nationally, we must be willing to consider new approaches and develop a mindset that transcends party politics. This may sound counterintuitive, but to reign in ever-increasing healthcare costs and enhance better population health, we should explore new solutions ‘upstream’ to invest in our collective health and well-being. This is not about implementing ‘socialized medicine.’ It’s about using our limited resources more wisely on key determinants of overall health that can ultimately improve health and control healthcare costs.

Healthcare Spending

In 2014, we spent 17.5 percent of our economy on healthcare, reaching $3 trillion annually. By comparison, in 1960, we spent only five percent on healthcare. One disturbing estimate by the Institute of Medicine shows about one-third of our healthcare spending – or $1 trillion – is widely considered wasted spending, money that can be better invested elsewhere.

Should healthcare costs dominate such a large segment of our economy? If so, shouldn’t we be healthier than other nations based on what we spend? On a per capita basis, the U.S. performs poorly on many key health indicators. For example, our country has lower birth weight, higher maternal and infant mortality, as well as higher incidents of injuries, obesity, diabetes, heart disease, chronic lung disease, disability rates, mental illness and, surprisingly, shorter life expectancy. In addition, we have more drug-related deaths than other industrialized countries.

With these in mind, one would think that most comparable countries must be outspending the U.S. on healthcare services. The facts are quite the opposite. In 2009, our country spent 16.3 percent of its gross domestic product (GDP) on healthcare, about six percentage points higher than the average 10.3 percent spent by 10 other industrialized countries. Yet, our growing appetite for more healthcare spending results in poorer health outcomes. This is both puzzling and frustrating – for policymakers, taxpayers, employers and their employees.

Social Services (Community Health) Spending

Instead of focusing on how to pay for healthcare – a perpetually-growing segment of our economy – we should re-direct our limited resources to impact basic social determinants of health, such as targeting education, housing, nutrition and poverty. Unlike healthcare, U.S. public spending on social services falls far below other developed nations. In 2009, the U.S. spent 9.1 percent of its GDP for aggregate social services versus the average of 15.8 percent spent by all 10 other wealthy countries.

When combined, U.S. healthcare and social services spending ranks in the middle of the pack of peer countries, with a disproportionately higher amount spent on healthcare than on social services.

The U.S. is the only wealthy country where healthcare spending accounts for a greater share of GDP than social services spending – an “imbalance” our country has embraced. Over decades, we’ve allowed soaring healthcare costs to smother the necessary investments we must make to improve our community health. In other words, our country inefficiently relies on medical care and insurance to address problems that we fail to address upstream, at their source. An insightful reference on this subject comes from a book written by Elizabeth H. Bradley and Lauren A. Taylor – The American Health Care Paradox…Why Spending More is Getting Us Less.

What can we learn from this?

High healthcare spending in the U.S. has far-reaching economic consequences, such as wage stagnation, personal bankruptcy and budget deficits. Extensive evidence suggests that making the right investments in social well-being substantially improves population health outcomes downstream. For example, housing vouchers, home energy assistance and the availability of supermarkets in low-income areas are known to reduce obesity, diabetes and nutritional risk in children. In addition, availability of prenatal and infant nutritional assistance is associated with reduced infant mortality.

Realistically, the American culture has had little appetite for becoming more ‘socialized’ in tackling upstream problems, relying instead on the national ideology that spending more on healthcare will solve our health woes and improve health outcomes. But for meaningful change to occur, balancing healthcare with social determinant strategies must emerge both nationally and locally here in Iowa. The Iowa Healthiest State Initiative, a nonpartisan, nonprofit organization, is just one example of attempting to improve the physical, social and emotional well-being of our Iowa communities. This initiative is a good start, but other bold private and public initiatives need to be undertaken for real positive change to occur in healthcare outcomes.

Investing in our health upstream makes a great deal of sense. Spending for the ‘right’ community measures that impact health will provide better health outcomes for Iowa and our country. Such expenditures will take time to translate into positive health outcomes but we need to start investing now. The result may be cost-shifting from inefficient healthcare spending to re-allocating funds for social determinants that matter most, such as nutrition, adequate housing and education. By doing so, we will make our communities and state both healthier and more productive.

Controlling health costs and improving population health – we cannot have one without the other.

Autopsies – The Ultimate Medical Audit

Posted on: 05.24.16 By: David P. Lind

Sixty years ago, about half of all patients who died in hospitals were autopsied to determine the cause of death – which also advanced the knowledge of medicine. In fact, autopsies were considered routine. For some family members, autopsies provided a sense of closure that was desperately needed during an emotional time.

By 1971, this practice changed dramatically when a decision by The Joint Commission – a federal organization that accredits healthcare facilities – dropped the autopsy requirement rates for community hospitals and teaching facilities, which were 20 percent and 25 percent, respectively. Simply put, the practice of performing autopsies on a regular basis was no longer in vogue.

At the time, hospitals were simply performing autopsies to comply with this requirement – not to gain medical insight. Largely due to autopsy cost, which were generally paid by hospitals, medical providers pressured the commission to eliminate the requirements altogether. The commission eventually relented, as it was determined that too many hospitals were performing shoddy autopsies that revealed little additional information to advance the understanding of diseases and the effectiveness of various treatments.

Today, approximately five percent of patients who die in hospitals receive an autopsy. As many as 40 percent of hospitals don’t perform autopsies at all. Many of the autopsies that are performed – such as for the musician, Prince – are to discover any evidence of foul play or suspicious circumstances, perhaps requiring a government-assigned coroner or a medical examiner to review the case. Due to the nature of educating medical students, teaching hospitals are more likely to undertake autopsies than non-teaching facilities. But the decline in autopsies most assuredly means the death certificates are not likely to be as accurate when determining the cause of death.

At a family’s request – and their own expense – autopsies can still be performed. But due to sensitivity and cost issues (an autopsy can run $1,500 or more), most grieving families shun autopsies. Health insurance companies do not cover the cost of autopsies because it does not relate to the health or well-being of a living person.

Moving beyond the cost and sensitivity issues, autopsies do provide a great deal of value to the medical world. Studies show that doctors make diagnostic errors in about 25 percent of cases. These errors remain unknown due to the absence of autopsies, consequently resulting in incorrect information used on death certificates.

In 1998, the Journal of the American Medical Association reported that autopsy results revealed that clinicians misdiagnosed the cause of death up to 40 percent of the time. Other studies indicate that 10- to- 30 percent of autopsies performed reveal previously undiagnosed conditions, many by unreported medical errors. It would be intriguing to know whether fewer medical errors occurred in hospitals when autopsies were more prevalent. Unfortunately, we don’t have such data to definitively render such comparisons.

It stands to reason that autopsies may provide additional learning for physicians and hospitals during weekly or monthly peer review meetings, allowing for new initiatives and policies to emerge that will avert future medical errors. Such evaluations can only come from the autopsy table.

Resuscitating the slow death of the autopsy may actually be a solution to learning more about the frequency of fatal medical errors and to advance the scientific knowledge of medicine. With at least 30 percent of health costs being considered ‘wasted’ cost, why not divert a small portion of this waste to reveal truths we must eventually confront?

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Preventable Fatalities in Hospitals
Gathering the Right Statistics

Posted on: 05.13.16 By: David P. Lind

Silent Death: Approximately 252,000 patients die annually in hospitals due to preventable medical mistakes.

Silent Death: Preventable medical errors in hospitals.

A recent report published in The BMJ by Dr. Martin Makary and Michael Daniel, both from Johns Hopkins University School of Medicine, generated a great deal of national exposure from the mainstream media – and for good reason. We have known for years that fatalities due to preventable mistakes made in U.S. hospitals are enormous. In fact, medical errors are the third-leading cause of death in this country, behind only heart disease and cancer. But the number of medical-error fatalities are seldom reported or collected by local and national health officials.

The report estimates that about 251,000 patients die annually in hospitals due to preventable medical mistakes. However, this is considered to be a low estimate because the authors tracked only errors documented in health records, and included only hospital patients. For many obvious reasons, mostly due to malpractice and reputation concerns, medical errors are grossly underreported.

In addition to the report, the authors published a letter directed to the U.S. Centers for Disease Control and Prevention (CDC) suggesting that death certificates have serious limitations by not listing the preventable complications that contributed to the death of patients. The authors, no doubt, agree with our ‘Silently Harmed’ white papers which state “preventable harm in hospitals appears to be an epidemic, and until it is exposed and meaningful reporting methods are embraced and enforced, we have no clear process to measure improvement.”

The United States currently uses a collection system on national health statistics that does not track medical errors. Death by diagnostic and medication errors, communication breakdowns and other system errors are not counted nor included on the death certificate. This is because U.S. health statistics are based on International Classification of Disease (ICD) codes, instituted in 1949.

Bob Anderson, chief of the CDC’s mortality statistics branch, told National Public Radio recently that such reporting would be hard to change “unless we had a really compelling reason to do so.”

This particular comment struck a raw nerve with me. I can think of at least 251K+ ‘compelling’ reasons to change how we track mortality statistics in this country!

When will we finally break away from our adherence to past practices and realize that for medical outcomes to eventually improve, we must accept and embrace new priorities that will address the third-leading cause of death in the United States? For real progress to take hold in healthcare, we must first confront the brutal facts by gathering pertinent measurable statistics to serve as concrete benchmarks for future improvement.

Now that would be compelling!

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Disparate Views on Patient Safety Progress

Posted on: 04.14.16 By: David P. Lind

When it comes to patient safety progress in the U.S., are we better off today than we were 17 years ago, when the Institute of Medicine’s seminal report “To Err is Human” was published?

Depending on the source (and their particular perspective), the answer to this question can vary widely.

As outlined in our ‘Silently Harmed’ white papers, the measurement of medical errors within hospitals is, quite frankly, abysmal. However, there are pockets of success – such as infection rates – that have dropped in hospitals. This past December, the Agency for Healthcare Research and Quality (AHRQ) issued findings that indicate decreases in infections, medicine reactions as well as other complications from 2010 to 2014 that have resulted in 2.1 million fewer incidents of harm – and 87,000 fewer fatalities.

In Iowa, an editorial by Dr. Tom Evans in the Des Moines Register acknowledged that preventable medical errors do exist – but that “significant improvements” have been made over the past 10 years. Further, data suggests that adverse drug events were virtually eliminated (99.9 percent), pressure ulcers were reduced by 89.4 percent, central line-associated infections decreased 34.7 percent along with many other improvements that were made in less than four years. These “downright impressive” results brought an avoidance of 3,310 adverse events, 15,603 fewer days in the hospital, and more than $50 million in cost savings.

Such public messages appear to be a good start, but make no mistake, we should refrain from performing a celebratory dance in the end-zone as if a game-deciding touchdown was scored. Continuing our football analogy, some notable national experts may suggest that the ball has advanced only a few yards, but far shy of reaching a new set of downs.

The fact is, when it comes to actually reporting adverse events, we don’t know what we don’t know. In other words, we can only measure what is being reported.

A recent report from Leapfrog Group and Castlight Health finds that computer systems in hospitals fail to flag 13 percent of potentially fatal mistakes, while about 40 percent of the most common medication errors were not caught when tested. In 2014 alone, the Centers for Disease Control and Prevention (CDC) indicates that a life-threatening bacterial infection, called Clostridium difficile (C. diff) has sickened over 100,000 American hospital patients. The CDC reports this particular infection has increased by four percent between 2013 and 2014, while other research suggests that 450,000 people, both inside and outside of U.S. hospitals, are affected by this infection each year, resulting in 29,000 fatalities.

I have periodically heard that patient safety experts in academia are not living in reality, as they tend to use their own theoretical acumen and measurements that seldom match up with the ‘real world’ of care delivery. Perhaps this may be true in some cases, but many of these same ‘academia’ experts also practice medicine for a living and have a great deal of passion to ‘simply do the right thing.’ They avoid projecting a false sense of security that our care is safer than it really is. Doing so can be disingenuous – if not grossly misleading.

A short list of highly-accomplished individuals that are on the forefront of patient safety in the U.S. and worldwide include: Dr. Ashish Jha, Harvard School of Public Health; Dr. Martin Makary, Johns Hopkins University; Dr. Peter Pronovost, Johns Hopkins; Dr. Atul Gawande, surgeon at Brigham and Women’s Hospital (Boston); Dr. Lucian Leape (retired from Harvard); Dr. Robert Wachter, UCSF Medical Center; etc. This list is long and impressive. They are not fearful about holding up the mirror to other clinicians and provider systems and challenging them to measurably improve their outcomes based on what is most important to patients.

On March 23, ProPublica held a webcast forum to discuss the value of the Surgeon Scorecard that became available to the public in 2015. Given the lack of specific risk-adjusted data we have on individual clinicians, it was interesting to hear arguments on both sides about the evolution of clinician scorecards available for public use. Toward the conclusion of the forum discussion, Dr. Jha was asked to summarize the progress of patient safety since the IOM report went public 17 years ago. This particular comment was quite revealing:

But at the end of the day, are we measurably and meaningfully safer today than we were 17 years ago? Personally, I would argue the data suggests we are not. We are not meaningfully safer than we were.

Again, time to ‘huddle-up’ and find new ways to advance the ball down the field. Let’s hope that a celebration will eventually take place in our collective future!

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A Documentary Film about Medical Errors

Posted on: 04.07.16 By: David P. Lind

During the last two decades, I have spent considerable time researching key factors that influence and impact healthcare costs, primarily due to my work with employers who relied on our guidance and strategies to obtain employer-sponsored health coverage.

It was through this work that I increasingly became familiar with the name, Dr. John M. Eisenberg. I would soon learn that Dr. Eisenberg was not only a physician dedicated to his profession, but was highly distinguished throughout his career while advancing evidence-based research in healthcare at the policy, practice and management levels. One of the many accomplishments he had in his short life was serving as director of the Agency for Healthcare Research and Quality (AHRQ), formerly known as the Agency for Health Care Policy and Research.

Without a doubt, Dr. Eisenberg was a worldwide pioneer on patient-safety issues, as he authored more than 150 articles dedicated to policy and scientific initiatives relating to the safe delivery of quality care that Americans trust they receive. Unfortunately, this passionate man who truly made a dent in our healthcare-related universe, died from a brain tumor in 2002 at the age of 55. Dr. Eisenberg was essentially a rock star within the medical world, as he was highly respected by his peers. In fact, the National Quality Forum (NQF) annually recognizes individuals and organizations that improve patient safety and healthcare quality through the establishment of the John M. Eisenberg Patient Safety and Quality Awards. These awards are being presented at NQF’s Annual Conference on April 7-8, 2016, in Washington, DC.

This past February, within a week after the Des Moines Register published their editorial on lethal medical errors – an editorial that was prompted by the release of our Silently Harmed white papers – I received an email from an organization, Tall Tale Productions, located in Chicago. The author of the email, Mike Eisenberg, mentioned he had recently read the DMR article and consequently downloaded one of the Silently Harmed papers. Mike is Dr. Eisenberg’s son.

Mike, inspired by his father’s work, plans to direct a feature documentary on patient safety, tentatively titled, To Err is Human, using the same name from the seminal book released in 1999 by the Institute of Medicine. Expect to find stories of patients and families who were adversely impacted by medical errors, in addition to interviews with patient safety-experts who continue Dr. Eisenberg’s work. Tall Tale Productions is in the final stages of their campaign to raise money to underwrite the cost of this important film. To learn more about how to contribute to this documentary, you can contact Tall Tale Productions.

Seldom do I tout particular causes within my posts, but I made an exception this time. Patient safety is paramount to us all.

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Diagnostic Mishaps

Posted on: 03.03.16 By: David P. Lind

Over 40 years ago, our family owned a 1975 Ford Granada that was very temperamental, dying at stoplights and stop signs for no particular reason. Much too often, we would take the car to the local Ford dealership, only to learn the cause of this problem could not be correctly diagnosed. Other than trading in the vehicle for a more reliable model, it seemed that running stop lights would be our only other viable option!

Since the release of our Silently Harmed white papers, one particular section has brought a great deal of intrigue and discussion from many people who have reviewed this paper and provided feedback. The section, ‘National Data on Common Adverse Events,’ addresses seven common adverse events found within our hospitals. Not mentioned within the seven, is misdiagnosis events, which are also very common – and harmful.

Indeed, according to the journal BMJ Quality and Safety, at least one in every 20 adults (about 5 percent) who seeks medical care in a U.S. emergency room or community health clinic, may walk away with the wrong diagnosis. The analysis estimates that 12 million Americans a year could be affected by such errors.

Of those mistakes, about half – or 6 million – could potentially cause harm, according to patient safety expert Dr. Hardeep Singh, who is the first to provide robust population-level data on the impact of the problem in outpatient settings. Patients with conditions as varied as heart failure, pneumonia, anemia and lung cancer could have serious problems that remain unrecognized by a doctor.

Other safety experts laud this finding as ‘hard evidence’ about the frequency of such mistakes. Some even argue that 5 percent is the minimum because these numbers overlook other error activity.

In 1997, the National Patient Safety Foundation (NPSF) commissioned a phone survey reviewing patient opinions about medical mistakes. Of the people reporting a medical mistake (42%), 40% reported a “misdiagnosis or treatment error,” but respondents did not separate misdiagnosis from treatment errors. Respondents also reported that their doctor failed to make an adequate diagnosis in 9% of cases, and 8% of people cited misdiagnosis as a primary causal factor in the medical mistake. Loosely interpreting these facts gives a misdiagnosis range of 8% to 42%.

The reasons why outpatient doctors misdiagnose patients can vary widely. Time with patients is more limited than ever and their symptoms are often complex and evaluated in what is described as “a fairly chaotic outpatient environment.” Many doctors lack the support and technical help that could free them to use consistent clinical reasoning. Adding more people to insurance coverage, a premise of the Affordable Care Act, can also stress the care delivery infrastructure, perhaps compounding an already fragile environment.

Just as Silently Harmed has attempted to grasp the number of hospital medical errors within each of the seven midwestern states, putting a population-level number on outpatient diagnostic errors can be a step toward generating greater awareness and resources to address the problem.

For patients, this important analysis should be a reminder that the doctor is not always right. Patients can play a key role in their own care by offering doctors a complete list of symptoms and a full-health history at the first visit. After the exam, they should be proactive about following up.

Unlike owning and operating a defective automobile, receiving a correct medical diagnosis from our trusted provider is critical to our physical and mental wellbeing. When it comes to our health, trade-ins are not optional.

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A New Employer Mindset Needed To Avoid Repeating Healthcare ‘Time Loop’

Posted on: 01.13.16 By: David P. Lind

In the 1993 movie, “Groundhog Day,” actor Bill Murray plays a Pittsburgh TV weatherman who finds himself in a comical time loop while covering the annual Groundhog Day event in Punxsutawney, PA. Murray’s character wakes up each day to relive February 2 and eventually learns how to use his prior-day experiences to make a difference within Punxsutawney. But it takes him many, many attempts and frustrations before he realizes he must re-examine his life and priorities before he can make desired progress.

I was recently approached by a very large Iowa organization interested to know my ‘take’ on the next phase of employer-based health coverage. Specifically, I was asked how to break the endless cycle of doing the same things over and over again to control health costs – as current attempts seemingly do not move the cost needle.

This particular organization assuredly represents most employers when it comes to the frustration of offering health coverage to their workforce. Much like the Murray character, employers continue to relive their renewals, year-after-year, only to repeat past practices that invariably result in a similar and familiar fate. A handful of these annual activities typically include the following:

Changing insurance companies or third-party vendors, including pharmacy benefit managers, wellness vendors, insurance brokers, etc.
Increasing employee cost-sharing components, such as deductibles, co-payments and out-of-pocket maximums
Limiting (or expanding) provider networks
Embracing consumer-driven health plans
Converting to a new financial mechanism to pay for coverage, such as self-funding, partial self-funding and a host of other hybrid funding arrangements

To avoid repeating similar (and predictable) results from these practices, employers should take a page from Murray and re-examine their priorities. Here are three ‘takes’ that I shared with this particular organization:

Employers Must Recognize and Accept that Preventable Medical Mistakes is a HUGE Problem

Employers should not assume employees and their family members will consistently receive safe and appropriate care from the local provider community. Even the best and most prestigious hospitals are not immune from committing these errors. Preventable mistakes are VERY costly, both in lives and in money. According to the Robert Wood Johnson Foundation, poor quality-of-care costs employers at least a third of the single-health premium. In Iowa, this would conservatively amount to $1,850 per employee each year. The social costs due to preventable medical errors dwarf this amount.* Just as importantly, eliminating preventable mistakes will also result in employees and family members living healthier and more productive lives.
Insist that Patient Safety becomes a PRIORITY

In the past, employers have relied on healthcare providers and insurance companies to control costs and quality, assuming that patient safety was naturally baked into the services we purchase. Yet, employers unknowingly pay for medical errors – albeit at the lower-negotiated fee available through insurers – but such discounted ‘savings’ are eventually negated due to paying for undocumented preventable mistakes. Employers and employees (not insurers) are the ultimate payers for this wasteful and unnecessary cost through higher insurance premiums. And, because of this, they must insist that new health plans deny payment for preventable medical errors. At the very least, this should be a minimum requirement. Few private plans attempt to do this, primarily because they have scant metrics to detect these errors. How would they know?
Require public TRANSPARENCY from local providers

The word ‘transparency’ has become an overused word – especially within healthcare. But for the ultimate payers of healthcare (employers and employees) to determine the value they receive from the ‘investment’ they make, the provider community must enter the 21st Century and demonstrate their value by publicly reporting comparable and usable safety information. This should also be a minimum requirement.

Offering and paying for expensive health insurance coverage year-after-year is the ‘Groundhog Day’ confronting frustrated employers. Unless a new mindset takes hold in the employer community that can forever alter our perpetual ‘Groundhog Day,’ very little will change in our ‘town’ of Punxsutawney.

*Additional details to follow over the next month.

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Fixing Core Issues ‘Upstream’ will help Reduce Healthcare Costs

Posted on: 10.01.14 By: David P. Lind

I’m far from being a political junkie. In fact, watching sausage being made is more gratifying than watching the legislative process in Washington D.C. – especially when it comes to health policy issues.

In late July, I attended a healthcare symposium arranged by the Iowa Association of Health Underwriters. Jesse Patton and his team did a wonderful job of mixing local with prominent national presenters. One particular speaker, Grace-Marie Turner, president of the conservative-leaning Galen Institute, gave an informative presentation and followed up with this question to the audience: “What fresh ideas and a new vision might you have for lawmakers to consider regarding healthcare reform (presumably following the 2014 and 2016 elections)?”

Grace-Marie asked an interesting question, and this one got me thinking.

Regardless of our political leanings, we can all agree that the Affordable Care Act (ACA) is very complex and the long-term outcomes are uncertain. We can agree that the path we are on is unsustainable for many caustic reasons. We have little systematic health policies, just band-aid approaches that mask symptoms of gigantic problems undermining our economic (and physical) well-being.

In addition to covering more Americans, the ACA has attempted to address the ‘downstream’ activities of ‘Our Health Care River,’ basically determining who should pay and by how much. This discussion is extremely divisive because it becomes muddled by partisan philosophies so toxic that any potential progress is quickly thwarted. As a result, the common good of all U.S. citizens becomes a pawn within the political playground. We have been down this road countless times and it is extremely difficult to accomplish anything of great substance. It is so much easier to disagree than to agree. And, as a consequence, we all lose.

We have become so fixated on cost (and access) issues that we lose sight of the primary source of this cost — the healthcare we receive from those providing it.

Unfortunately, very little policy-making attention has been spent ‘upstream,’ which is the primary reason we are drowning in high healthcare costs (and insurance premiums) in the first place. Upstream problems should be a non-partisan issue. Because of this, we must agree on some fundamental issues that impact what we eventually pay downstream. So what are the core issues that will allow both political parties to find common ground and begin the change process? Here are a few…

We must:

Have complete transparency in medical costs and outcomes.
Address poor coordination of care among providers.
Identify and fix the reasons why recommended care is alarmingly low.
Remove the waste and inefficiency baked within our healthcare costs that we eventually pay “downstream.” When you factor in the loss of productivity due to medical errors, this equates to at least a trillion dollars annually – at least 40 percent of all health costs!
Develop and implement approaches to unmask and eliminate the medical mistakes that occur each year in our hospitals – which result in hundreds of thousands of needless deaths. In addition, 10-to-20 fold more are seriously harmed due to medical mistakes – in just our hospitals. Eradicating simple medical mistakes from our healthcare delivery system will provide safer care while eroding medical malpractice claims.
Identify and resolve the misalignment of payment to healthcare providers. This has created perverse incentives that result in overtreatment, undertreatment, and other unintended consequences that we can no longer afford. We can all agree that fee-for-service payment measures must be replaced with sensible payment policies that promote incentives for performing the right care at all times.
Address our unhealthy lifestyles which create additional pressure on an already dysfunctional healthcare ‘system.’ I know, this is easier said than done – but it is the truth. Developing a ‘social conscience’ about living healthier is a good start.
Not allow lawmakers to be unduly influenced by lobbyists who compromise the well-being of our citizens. Washington (and state) lobbyists have perpetuated the ‘medical industrial complex’ that continues to eat up more of our gross domestic product.

Does this sound impossible to you? Perhaps, but maybe not. For heaven’s sake, we put a man on the moon 45 years ago – and we did it by using technology from the 1960’s! We just need to have the political will, and frankly, a backbone to confront the brutal facts.

There are many other core issues that might be considered, but the above list is a good beginning on finding common ground. By addressing these issues, the cost to our system will drop markedly, making the political decisions downstream more manageable, and consequently, more favorable for agreement from both sides of the aisle. In fairness, the ACA attempts to address a few of these initiatives upstream, but most health experts agree that such programs will most likely have marginal consequences to the real problems occurring upstream.

Because our spotty health outcomes do not discriminate between classes of people within our country, policymakers must ‘think more like a patient’ and engage their efforts into reforming the core topics above. After all, policymakers are patients too. Carefully-derived factual data can guide and persuade policymakers to address these core issues. But it may take a “patient-like” mentality to properly motivate elected officials to do the right thing for all citizens.

If we continue our past practices in healthcare ‘policy’, we will replicate what baseball-great Yogi Berra was credited for saying: “It’s like deja-vu, all over again.” Our nation can no longer afford to continue down this dangerous road.

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Voices on Hospitals: Cost Transparency and Keeping Cost Reasonable

Posted on: 08.13.14 By: David P. Lind

In early 2013, I developed an infographic to help ‘mask the complexity’ of our complicated healthcare ‘system.’ The infographic portrays an overview of ‘Our Health Care River’ that illustrates how upstream activity can adversely impact what happens downstream.

We all know the health insurance premiums we pay are nothing more than a derivative of healthcare costs plus administration fees. Employers have spent enormous energy, time and money, downstream trying to ‘fix’ the symptoms of major pollutants found upstream, as depicted in ‘Our Health Care River.’ Major ‘chemicals’ found upstream include a ‘Fragmented Delivery System‘ and ‘Unhealthy Lifestyles.’

Year-after-year, employers tweak their health plans to keep them affordable. They do this by increasing deductibles, out-of-pocket maximums, office and Rx copayments, employee contributions, limiting provider networks, etc. However, we can only do so much downstream because combating just the symptoms of the core problem will only prolong the annual frustrations that we all will continue to face.

Below are the final two performance indicators on hospitals as perceived by employers: ‘Cost Transparency’ and ‘Keeping Cost Reasonable.’

Indicator #11: Cost Transparency

How can patients and payers discern the ‘value of care’ delivered when cost is not commonly known at the time the procedure is being delivered? For ‘value’ to be accurately determined, providers must measure costs at the medical condition level, which requires a true understanding of all the resources used in the patient’s care.

By having this information, the cost of providing care to a patient per episode-of-care can be compared to the outcomes achieved for that particular condition. It must begin with understanding the true cost of care. The transparency of this cost to the public is crucial.

Statewide, Iowa employers rated hospitals a score of 5.8 on a 10-point scale. In other words, employers gave hospitals an un-weighted ‘D+’ on cost transparency. When segmented into five regions using size-weighted scores, three regions ‘fail’ while the southwest region (5.1 score) was a whisker away from failing. Only the northwest region was safely graded above failing, grading in at a ‘mid-D.’

Indicator #12: Keeping Cost Reasonable

Our 12th indicator – ‘Keeping Cost Reasonable’ – is a cousin to ‘Cost Transparency.’ This indicator is extremely frustrating to Iowa employers and earned the lowest grade when compared to the other 11 performance indicators. Increasing value requires either improving the outcomes without raising costs or lowering costs without compromising outcomes. From our past 15 years of research, Iowa employers have seen health insurance premiums increase by 171 percent for single coverage and 158 percent for family – clearly an unsustainable pace.

Statewide, Iowa hospitals received an abysmal score of 5.1, or a grade of ‘D-minus’ for their efforts on keeping costs reasonable. When segmented into five regions using size-weighted scores, four regions ‘fail’ while only the northwest region received a ‘mid-D’ grade. Polk County hospitals received an extremely low score of 3.4, based on 144 employers within that county.

Within their respective communities, employers must lead the discussion about healthcare ‘value’ – for one major reason: they own the problem. The path that we are all on is unsustainable AND unacceptable. Unilaterally, providers are unable to develop ‘solutions’ to the cost problem. Employers must be part of the solution by moving upstream to help find approaches to prevent the harmful ‘chemicals’ from polluting ‘Our Health Care River.’

To learn more, we invite you to download our free white paper: ‘Voices for Value: Iowa Employer Perceptions of the Iowa Healthcare Provider Community.’ This document provides a comprehensive overview on our current status and establishes a baseline in which to measure future changes made in Iowa’s healthcare system.

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Voices on Hospitals: Efficiency and Coordination of Care among Providers

Posted on: 07.30.14 By: David P. Lind

Evidence remains strong that the U.S. healthcare ‘system’ is not efficient. In fact, according to the Institute of Medicine, about one-third of the $2.6 trillion spent on healthcare in the U.S. in 2010 was identified as being wasteful and inefficient.

In healthcare, cost and quality do not correlate with one another. Some lower-cost physicians (and hospitals) can produce high-quality care, while some high-cost health providers produce low-quality care. As stated in our ‘Voices for Value’ white paper, rewarding and making transparent cost, quality and safety measures will lead to improved efficiency without adversely affecting quality.

Indicator #8: Efficiency

When assessing the efficiencies of hospitals within their communities, Iowa employers give statewide hospitals an un-weighted score of 6.5, or a grade of ‘C.’ When segmented into five regions using size-weighted scores, four regions received ‘D’ grades, while the northwest region received a ‘mid-C’ grade.

Indicator #9: Coordination of Care among Providers

If there is one performance indicator that can be very frustrating to patients, care coordination among providers might be the one most widely criticized.

According to the Agency for Healthcare Research and Quality (AHRQ):
“Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care. This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.”

Within the five Iowa regions, employers view ‘coordination of care’ efforts similar to ‘efficiency’ standards – in other words, no ringing endorsements from employers. Employers give statewide hospitals an un-weighted score of 6.4, or a grade of ‘C.’ When segmented into five regions using size-weighted scores, the northwest region scored a ‘mid-C’ while the other regions received ‘Ds.’

Interestingly, hospitals in Polk County received a failing grade (‘F’) when graded by 144 Iowa employers within that county. Needless to say, key hospitals in Polk County have plenty of room for improvement in this category.

When Iowa employers experience annual premium increases that exceed the overall inflation rate, it is reasonable to expect health outcomes delivered to be at least commensurate with the inflated premiums they pay. Achieving high value for patients must become the overarching goal of our healthcare delivery system, with value simply being defined as “the health outcomes achieved per dollar spent.”

Without question, Iowa employers do not believe they are receiving top value healthcare for what they are expected to pay.

Next week, we will review how Iowa employers graded hospitals on ‘Transparency in Medical Outcomes’ – performance indicator #10 in our “Voices on Hospital” series.

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