Archive for 2006

The Downside of Performance Measures

December 28th, 2006 by Melanie Matthews

The thing about performance measures is there can be a lot of caveats to the type of care given and the result – many of which can’t be reflected in a report card on the quality of care given at a hospital or by a physician.

Take for instance C-section rates. While the aim in labor and delivery is to have a low C-section rate, C-section rates can be influenced by patient risk factors (e.g., multiple pregnancy, previous C-section, greater than 36 weeks gestation, medical risk including hypertension, diabetes, etc.). However, most times, the reported C-section rates are not adjusted to reflect these factors, according to an article on the Michigan Hospital Association web site.

A woman I know had her first child this week. Weighing in at 10 lb. 2 oz., this baby spent its first two days of life in the NICU for problems related to a vaginal birth — problems that would have been avoided had a C-section been performed. The baby is also now going to physical therapy to hopefully fix an injury to his arm related to his birth.

This birth’s impact on the C-section versus vaginal birth rates would make the hospital’s quality ratings appear high, but a C-section would, indeed, have provided better quality care than this vaginal delivery.

Class-Action Lawsuit Highlights Importance of Healthcare Price Transparency

December 19th, 2006 by Melanie Matthews

A recent class action lawsuit in Seattle detailed in the November 16th USA Today is another example of the need for price transparency in the healthcare industry.

The lawsuit, filed against Virginia Mason Medical Center, stemmed from a patient name Lori Mill who was concerned about a possible toenail infection. She went to her doctor’s office in an outpatient clinic owned by the Virginia Mason Medical Center in downtown Seattle. Her doctor clipped off a piece of nail and sent it to the lab for a total cost to Ms. Mill of $1,133. Mill found out later that she could have paid hundreds less for the same thing had she gone to one of Virginia Mason’s seven other, more suburban, outpatient clinics, where her doctor also practices.

Her situation illustrates a practice that is legal and common, but little known to patients: Some medical clinics are considered “hospital-based” and charge additional fees for the same services, even if they aren’t inside an actual hospital.

The lawsuit argued that, under state consumer protection laws, patients should have been told in advance about additional fees.

Earlier last month, Virginia Mason settled the class-action law suit, agreeing to not only refund money to thousands of patients, but also to tell patients that it charges more at some clinics in its system than others and to find ways to help patients estimate upfront their costs for some outpatient procedures.

As consumers become more responsible for how their healthcare dollars are spent, it is only realistic that we ask for and are given the knowledge to make an informed decision. During “Meeting the Demands of Healthcare Transparency in Pricing and Quality,” an HIN audio conference on this transparency movement, Dr. Lou Diamond, medical director with Medstat and Paul F. Thompson, product marketing manager with Cigna, provided insight on healthcare cost and quality transparency.

In Ms. Mill’s case the facility fee was $418. I know put in her shoes, if I had been told of such a fee, I would have thought twice and sought an alternative to care in that particular clinic – I’m sure you agree.

Managing Transitions to Care for Medicare Patients to Avoid Costly Inpatient Admissions

December 14th, 2006 by Melanie Matthews

Miscommunication during the care transition puts elderly patients at risk for reduced quality of care, poorer outcomes and unnecessary procedures, according to Gregg Lehman, president and CEO of Inspiris. He defines the key players on the care transition team, suggests strategies for improving communications during this crucial phase and describes his organization’s approach to dual eligibles who find themselves at this healthcare crossroad. Click here to listen to Gregg’s comments. Lehman, along with Danielle Butin, director of health services at Oxford Health Plans, a United Healthcare Company, described how their organizations are coordinating the care of Medicare patients as they transition through the healthcare system to minimize costly episodes of care during a November 30th audio conference, Managing Transitions to Care for Medicare Patients to Avoid Costly Inpatient Admissions. For more information, please visit: Managing Transitions to Care for Medicare Patients to Avoid Costly Inpatient Admissions

Growth and Impact of Web-Based Quality Ratings

November 10th, 2006 by Melanie Matthews

In reviewing some notes this week from a previous audio conference hosted by the Healthcare Intelligence Network, “Healthcare Report Cards: How To Get an A+ in the Public Reporting of Healthcare Quality Data,” I came across a reference to the growth of hospital report cards – the reference point was in terms of Google search results. In January 2005, there were 700,000 results for this term. Six months later there were 3 million. And, just a few minutes ago, there were 12.3 million.

Not only are hospitals posting this type of data about their organizations, but more and more health plans are starting to post quality indicators from hospitals in their networks on their sites.

What does this all mean for the consumer? Probably not too much for someone making an emergency visit to the hospital, but for planned episodes of care, the impact can only grow. As consumers, we are becoming more accustomed to researching our purchases online, be it “Consumer Reports”-type information or opinions of goods and services.

Just the other day, I went on a web site to see the difficulty rating of a Halloween craft that I was going to help first grade students make at a class party. A few years ago, it would not have occurred to me to look for this type of information online. However, the availability of this information, no matter what the content, continues to train me as a consumer to use the web as a source of ratings before making a final buying decision when given the opportunity.

The Importance of a Medical Home

October 25th, 2006 by Melanie Matthews

During an audio conference call last week that focused on strategies for reducing non-urgent emergency room usage, our two presenters, Roberta Burgess, clinical case manager, Community Care Plan of Eastern Carolina and Jerry Kiplinger, executive director, APS Healthcare, stressed the importance of the creation and use of a medical home as one strategy to reduce unnecessary ER usage.

As a relatively healthy woman without a whole lot of health issues (knock on wood), I found myself digging a little deeper into this concept. Examining my own healthcare utilization, I do agree that if I had had a medical home, I could have avoided a non-urgent visit I made to the ER within the last 18 months. I had taken a bad fall and thought I had a broken bone or two. Without a primary care or family physician to call my own (or should I say home), I went to the ER for the sole purpose of X-rays. Had I medical home to go to, I would have started there.

We’ve written quite a bit on ER utilization in the last few months. Most of the strategies seem to focus on the “frequent flyers” to the ER. While this is a critical part of an overall strategy, there is, I’m sure, an enormous opportunity to reduce even those non-frequent flyers, like myself, who did not have anywhere else to go.

I’m sure my “case study” gets repeated over and over again with slightly varying scripts among those who are not the classic frequent flyers. My health plan has not yet communicated with me about creating a “medical home,” but had they done so prior to my visit, I may not have made that visit.

Exercise in Disease Management: The Future Looks Rosier after 39-Mile Trek

October 17th, 2006 by Melanie Matthews

I’ve never been a big fan of pink. When I had my colors done in the eighties, I was informed that I was an “Autumn” and advised to pitch my pastels. But after participating in last weekend’s Avon Walk for the Cure in New York, I have proudly added to my wardrobe an assortment of t-shirts, hats and accessories in varying rose hues.

The neighborhoods and riverfronts of New York were transformed into a living ribbon of pink last weekend as 3,500 walkers covered up to 39 miles by Sunday afternoon. The shades of pink in evidence — blush, coral, flesh, flush, fuchsia, red, rose and salmon — were as varied as the ages, sizes and motivations of the walkers. But the triumphant walkers who filed into the closing ceremony at South Street Seaport were united in a solid field of fuchsia, the shade of the commemorative t-shirt handed to each finisher.

As Breast Cancer Awareness Month nears its halfway point, it’s gratifying to see so many local and national initiatives focusing attention on and raising funds for those affected by this insidious disease. During my 900-minute walking tour of Manhattan, 300 people were diagnosed with breast cancer, and another 65 individuals lost their lives to the disease. And as they told us at the finish, every walker has a story. I signed on to honor a friend battling the disease, as did many others. But there were hundreds of participants who walked in memory of family and friends.

This particular group of road warriors raised nearly $10 million for the cause, a record-setting tally for the Avon effort, which sponsors a series of weekend walks around the country each year. I’m proud to say I was part of the New Jersey-based “Clubs for the Cure team” that raised $500,000 of that total. The entire event was a study in organization, creativity, enthusiasm and emotion, from the themed rest stops to the choice of scented hand sanitizers in the porta-johns (Avon’s, of course) to the presentation of breast cancer survivors from 37 countries around the world. Along the way, we were supported by hundreds of enthusiastic volunteers who fed, hydrated, bandaged and cheered us to the finish line.

There is still much work and walking to be done until a cure is found. In the meantime, organizations like Avon are not only raising research funds but also underwriting the care and support of the medically underserved. Many of the grants to metropolitan medical facilities announced by Avon Foundation Executive Director Carol Kurzig at Sunday’s closing ceremony include funding to launch or extend patient navigator programs. The goal of patient navigator programs is to develop effective interventions to reduce cancer health disparities by facilitating timely, continuous access to quality, standard cancer care for all Americans.

I hope to participate again next year, and plan to take a few friends and sisters with me. And until they find a cure for breast cancer, I’ll continue to wear pink, even if it doesn’t look good on me. Because breast cancer doesn’t look good on anybody.

In Case of Emergency: Emotions Can Cloud Your Judgment

September 27th, 2006 by Melanie Matthews

I pick up a lot on this job that helps make me a wiser and healthier consumer — tips for evaluating healthcare benefits and providers and making smarter lifestyle choices. And I recently learned something else: how to figure out when to go to the emergency room (ER).

One day this month we were finalizing the description for an upcoming audio conference, “Non-Urgent Emergency Room Usage: Proven Ways to Redirect Care to Appropriate Settings.” That evening, my 17-year-old daughter began complaining of head and neck pain, the result of a minor car accident that had occurred that afternoon.

By the time she shared the news about the accident, our primary physician’s office was closed. Not entirely sure that this warranted an ER visit but also disinclined to downplay the risk from a head injury, I took her to the hospital emergency room at around 9 p.m.

Most importantly, her injuries were minor and we were sent home around 1 a.m. with a prescription for muscle relaxants and rest. However, during our four-hour wait for care, I had a lot of time to consider whether I had made the right choice in bringing her there. It was certainly a decision colored by emotion, made by a parent with their child’s best interest at heart. But if I had taken the time to research, I might have come across these guidelines from Health Pages, an online consumer healthcare service that provides a list of good reasons and bad reasons to go to the emergency room. Severe bleeding, signs or heart attack or stroke, loss of consciousness or a major injury such as a head trauma (which, I rationalized, was where we fit in) are some good reasons for going, according to this resource. Sprains, sunburns, rashes, fever (unless the patient is convulsing) and colds, coughs and flu are bad reasons for an ER visit.

Also, a little preparation now can help you make an informed decision in case you or someone in your care needs medical attention outside of doctors’ office hours:

ï‚· Get a primary care physician. Having a regular doctor who keeps your medical history on file, who is available to see you in a pinch and who will take your phone call outside of office hours is one of your best recourses in an emergency.

ï‚· Research other healthcare facilities in your community. Sometimes 24-hour walk-in clinics and minor emergency centers can care for non-urgent conditions faster and less expensively than a hospital ER.

ï‚· Keep important medical information on you. It’s a good idea to carry in your purse or wallet a small card that notes the name and telephone number of your regular doctor, any allergies or chronic medical ailments you may have, and any medications (along with dosage) you may be taking. Also jot down whether you are pregnant. This will save the ER doctor a lot of guesswork when trying to diagnose and treat your condition, particularly if you are unconscious.

ï‚· Locate the best emergency rooms near where you live and work. Not all hospitals are equipped to handle every emergency or even have emergency care. Emergency facilities are rated Level 1, 2 or 3. Those rated Level 3 are the most comprehensive trauma centers with high-tech equipment and specialists on the premises at all times. Level 1 and 2 centers can handle many kinds of emergencies, but may not have specialists on hand for some needs. Find out what type of emergency services are available at the medical facilities in your community.

ï‚· Review Insurance Coverage. Know which emergency services are covered and what instructions you need to follow in urgent situations. For example, if you go to an ER with an ear infection, your health insurance may not cover the cost. Also, some plans require that you notify them within a few hours of being admitted. If you don’t, your treatment may not be covered.

ï‚· If possible, call the ER before you go. There are no guarantees, but notification that you’re on your way may cut down on your waiting time by allowing the staff time to prepare for it. You will probably talk with a triage nurse who will ask you about your symptoms (or those of the person you are assisting) and will tell you whether you need to come in; whether to call the Emergency Medical Service (EMS), which can be reached in most areas by calling 911; what you can do before you arrive; what information you need to bring to the hospital; and whether you will be better off going to a different ER.

ï‚· Take advantage of your health plan’s 24-hour nurse line. Many health plans now provide a 24-hour nurse line that seeks to direct callers to the most appropriate level of care. Through one-on-one counseling available by phone any time of day or night, participants can make more informed decisions about their use of healthcare services.

The American College of Emergency Physicians also offers a list of warning signs that constitute a medical emergency.

Whether as providers advising patients or patients ourselves, we can do our part to reduce unnecessary ER utilization, preserving the service for those who need it the most.

Healthcare Self-Management: An Economic Model

September 22nd, 2006 by Melanie Matthews

Our managing editor returned to the office this week after covering the Health Management Congress in Las Vegas last week. An overriding theme at the conference, she reported, was patient self-management. How do we put the responsibility for healthcare in the hands of the consumer?

In this week’s edition of our newsletter, The Healthcare Business Weekly Update , Dr. Richard Citrin, the former vice president of integrated care management at CorpHealth, discussed the ways that CorpHealth determines if a person is ready to make a healthcare behavior change.

He reported that people change when the benefits of changing a behavior exceed the resistance – it’s an economic model. His comments were excerpted from “Motivating Resistant Patients: Influencing Behaviors to Improve Outcomes.”

Accepting responsibility for one own’s healthcare and making the necessary behavior changes that can impact health are all part of this self-management.

Diabetics who measure their blood levels, asthmatics who use peak flow monitors, overweight individuals who begin exercise programs and choose healthy food options are just some of the ways that this self-management is occurring in the industry – with help from insurance companies and disease management companies that are incorporating this type of self-management into their program design.

Health coaches, web-based health information and interactive voice response systems are all emerging as new tools in this self-management arena.

Offering these options are truly a great way to get people more engaged in their health and accept responsibility for the management of their own care. But unless it’s done with an economic advantage, the required behavior changes just might not be made.

In New Disease Management Model, Patient is Part of the Solution

September 19th, 2006 by Melanie Matthews

Decimated. Dying. Crumbling. Just a few adjectives used by presenters at the 11th annual Health Management Congress to describe the state of primary care in the United States. Discouraged by increased demands on primary care providers and reimbursement formulas that may eat into their expected salaries, 50 percent fewer medical students are choosing family medicine as a specialty. With patient visits limited to 10 to 15 minutes, primary care physicians don’t have time to address the behavioral issues associated with many chronic illnesses. In addition, their medical training has not prepared them to properly educate patients. While health plans and hospitals figure out how to woo more general practitioners into medicine and adjust reimbursement and education models, patients are being asked to take a more involved role in the management of their chronic illnesses.

Kate Lorig, a registered nurse, doctor of public health and professor of medicine at Stanford Patient Education Research Center, believes that patients themselves may be the best medicine — so much so that she has tapped them to lead her organization’s self-management programs for people with chronic illnesses. Over the last two decades, her organization has developed, tested and evaluated self-management programs for the chronically ill. “In order to help patients become better self-managers, we must raise their self-efficacy,” she said during a congress panel discussion on behavioral advances in effective health and disease management programs. “We must address the anxiety, depression and fear of the chronically ill before their behaviors can change.”

Led by a pair of lay leaders with related health problems, Dr. Lorig’s programs are designed to help people gain self-confidence in their ability to control their symptoms and understand how their health issues affect their lives. The small-group workshops for diabetes, arthritis, HIV/AIDS, back pain and chronic disease are generally six weeks long, meeting once a week for about two hours. The meetings are highly interactive, focusing on building skills, sharing experiences and support.

To listen to Dr. Lorig describe the identification and training of patient leaders for the self-management workshops, cultural considerations and other program details, please click here.

Many of the completed programs have been adopted by health plans, organizations, American cities and locations outside the United States for use in their disease management efforts. Several of the programs are offered in Spanish, and web-based versions of patient-led self-management efforts are being developed. Dr. Lorig’s team is currently seeking volunteers with type II diabetes to participate in a six-week online workshop. Participants will learn the skills needed for the day-to-day management of type II diabetes as well as maintaining or increasing life’s activities. To find out more about the program, please visit:

Health Management Congress Update: September 14, 2006

September 15th, 2006 by Melanie Matthews

What’s in a Name:

Welcoming attendees of the 2007 Health Management Congress, congress co-chairman Dr. Thomas J. Foels, associate medical director, Independent Health Association, reflected on the organization’s name change from Disease Management to Health Management Congress: “We are moving beyond managing illness to managing the entire continuum of care,” he said, and the new congress name reflects this direction.

Disease Management Industry Update: 2006 and Beyond

Four panelists shared their views on the challenges facing the disease management industry. One trend is a move toward a “patient-centered medical home,” a concept being refined by the American College of Physicians, represented on the panel by Michael S. Barr, M.D. Dr. Barr said his organization is focusing on improved quality of care, and in particular, improved quality of primary care medicine.

Dr. Alan Spiro, vice president and chief medical officer of Anthem National Accounts, a Wellpoint company, fears that the industry has become so focused on metrics “that it is missing the people.” “We’re falling down on engagement,” he told the congress. “Our goal should be to create simplicity in the system — provide a single phone number and point of contact for members and patients.” He said his organization is utilizing the concept of “primary nurse” who is the single telephonic contact for a patient. To hear a follow-up interview that HIN conducted with Dr. Spiro, click here.

Heard Around the Health Management Congress…

Reaching Out and Improving Diabetes Outcomes: After implementing an interactive voice response (IVR) system from the Eliza Corporation that makes contact with participants in its diabetes disease management program, MVP Healthcare has nearly doubled member engagement and increased member satisfaction with the automated outreach calls. (The company was formerly using live callers to reach out to members.) The effort identified 20 percent of members who experienced depression in conjunction with their diabetes. Also, of the 80 percent of members who felt that they were in control of their diabetes, the outreach identified significant numbers who had not had required tests (Microalbumin, LDL, HbA1c) in the last year. The diabetes outreach program provided physicians with actionable information about the member, which has been positively received by the providers. The system has the ability to “remember” past interactions to create ongoing dialogues with patients. (From Jerry Salkowe, M.D., vice president of clinical quality improvement, MVP Healthcare.)

Addressing Pharma Non-Compliance: In response to rising pharma costs in the early nineties, Pitney-Bowes put all generic and brand name drugs for asthma, diabetes and heart conditions in Tier I of its pharma coverage. By lowering the costs for drug therapies addressing chronic conditions, Pitney-Bowes improved pharma compliance among its 35,000 employees worldwide, according to J. Brent Pawlecki, M.D., the company’s associate medical director. He shared this strategy during a pre-congress workshop, “Harnessing the Power of Value-Based Healthcare – Managing Employee Health Throughout the Care Continuum.”

Addressing Cultural Considerations in Program Development: In the same session, Jenn Archure, senior director and team leader of Pfizer U.S. Pharmaceutical’s Healthy Directions program, described how her team customized the program for various locations. For example, when Pfizer launched the effort in Puerto Rico, families of employees were invited to share a nutritionally correct meal on company premises.