Robert Wood Johnson Foundation's CONNECT PROJECT guided meetings in Washington DC this week.  Six of the seven US pursuing perfection sites met with their congressional members.  The Whatcom county team consisted of Rebecca Bryson (patient), Marc Pierson (me, project executive), and John Hayward (CEO of PeaceHealth). We met with Senators  Patty Murray and Maria Cantwell and with Representatives Rick Larsen and Jim McDermott. The meetings were informational and well received. Each member agreed to work with us to learn more about what we are doing and to lend their support to comprehensive clinical quality improvement efforts.

There was also a meeting with the National Health Policy Forum. The subject was "Pursuing Perfection in Health Care Delivery: Insights from Innovators". There was good attendance by congressional staffers and health agency leaders. Donald Berwick, MD, led off and presented context for the briefing. Honor Page, the mother a patient with cyclic fibrosis spoke next. She gave the patient's or consumer perspective on the current status of health care as well as on her interactions with Pursuing Perfection project at Cincinnati Children's Hospital. Next was Dr. Brian Rank from HealthPartners, Bloomington, Minnesota, explaining the frustration and challenges from the perspective of a physician leader pursuing perfect care in today's environment. Finally John Hayward spoke about the need for change and his rationale for the work going on in Whatcom County, WA, as well as explaining his personal commitment to transformational change in his organization.

Rebecca, John, and I all felt like the relationship building with our congressional members is off to a good start. As you all know, for the improvement that we have started to be sustainable, both Medicare and Medicaid will need to become more flexible in matching payment to innovations in care. Our short and long term goals will be some small appropriation to help cover the short fall on our start up of this transformation, then a demonstration project that will provide the needed flexibility to this county. Ultimately the payment structure of Medicare and Medicare will need to be modified based upon the successes of the demonstration projects.

Click on this link if you would like to study most current recommendations by the Institute of Medicine to CMS (medicare/medicaid) for demonstration projects aimed an transforming health care and aligning payment. Four out of five proposed types of demonstration projects are highly aligned with what we have already begun with Pursuing Perfection and Robert Wood Johnson Foundation.

The "systems dynamics model" that you have built with two consultants is a breakthrough.  This model would be of help to every Pursuing Perfection site, and gives a new tool to the industry for exploration of the "business case for improvement."

 

1) Patients truly at the center, "radical patientcentricity"

2) First design the healtcare system that is needed.  Then and only then, design the payment system to support the idealized system design.

• Too frequently we have tried to create as system through manipulation of the payment structures. That is like trying to make a marionette dance through strings held by puppeteers who can't see each other, can't see the marionnette and don't agree on the dance.
• Only by working together can we get the dance steps right. This is the first order of business if we are to improve the patients' and providers' experience, and deliver the needed quility and value.
• In our Pursing Perfection project will use group systems dynamics modeling and simulation to design the dance for a couple of chronic diseases first.

Payers must help with the redesign or it will not be possible.

Sunday 6/16/02; 10:29:16 PM by MP (notes by Mary Minniti)

• This serves as documentation of the work of a small team scoping the systems dynamics work ahead. Attendees as the conference call were: Marc Pierson, Mary Minniti, Marcy Hipskind, Mark Donaldson and our consultants - Gary Hirsch and Jack Homer.
• The main focus of Phase 2 is to model the financial impact of changes in care to the various organizations and community. We will model both diabetes and congestive heart failure. The purpose is to define the reimbursement issue and provide information useful to impact policy decisions. Work will begin in July and conclude by Jan 2003. It will be used by GHC [and hopefully others] to make changes in policy for reimbursement.
• Two new areas of focus will be to model the effect of patients changing insurance companies and the % of patients who stay or leave the county as we are interested in the impact to each organization as well as the community. We will integrate into our model two concepts from John Wennberg's proposal to CMS (Medicare) - use of effective care and the effect of patient choice on the model.
• The remaining time was spent identifying data needs and next steps:
• The modelers will be in our community July 15 - 18th.
• Individual meetings will be set up with each organization. A overall meeting with all partners to summarize their work, will occur on the last day. Mary/staff to coordinate
• Individual phone interviews will occur with each organization's knowledge expert who has a broad view of the data in each system. Each site is asked to provide names and numbers of those individuals to Mary Minniti - who will forward to Jack and Gary by June 18th.
• A listing of the cost assumptions in the Phase 1 model will be provided and each organization is asked to review it for accuracy.
• A list of articles will be provided about CHF to Jack and Gary. These are review articles about the disease, best evidence and outcomes with various treatments and current thinking about disease management in this area. Roland Trenouth is providing the list.
• Contact with the other organizations (especially CMS and DSHS) on the call will be made to get the appropriate names of people to participate in the Systems Dynamics F2F and phone interviews work between now and July 15th. Mary and/or Marc will make these contacts.
• Marc and Mark will conference with Lynda Parton to share the approach of targeting appropriate folks in the insurance arena to provide information in this effort: Medical Director, Administrator/Operations person and Provider Relations person
• Marc will contact Kristen Crosby about CMS and her involvement in the modeling work.
• Data needs: [each organization will provide this information below to Gary and Jack for the modeling]
  • understanding cost structure - what are fixed vs. variable cost at the practice/insurance level for care to patients.
• Understanding revenue stream- understanding the different payment models for clinics/hospital. How do provider revenues changes if volumes change? What % of revenue are covered by different payment mechanisms?
• Mark Donaldson will do some follow-up to see if GHC could share the above data information from their clinic practices
• Mary will gather some information from HealthPartners regarding their % gain of efficiency or % cost savings from IDCOP so it can be placed into model as one gross variable.

 Our task list includes the following:

• Engage the other grantees in system dynamics effort, sharing knowledge with them as it accumulates
• Follow up on HBOC Offer
• Develop a contract with System Dynamics folks
• Scoping Meeting in June.
• Identify community business participation
• Week long SYS Dynam meeting with the local Systems Team
• Conduct community data analysis and costing for diabetes and CHF
• Identification and contact with employers and community resources for support
• Identification and contact with payors, national representatives for support in change in reimbursement model

A daunting thought for a cottege industry. It's a system. The only question is whether the stakeholders can create infrastructure to support a system.

• Recruitment and Hiring of Project Staff (Data Analyst, Project Manager, Project Coordinator)
• Hire Grant Writer
• Recruitment and Hiring of information technology staff (Web Content/patient Education; Programmers)
• Recruitment and Hiring of Team and Process Improvement Facilitator and Organizational Development (OD)
• Recruitment and Hiring of Care Managers
• Consultants and Contractors may be hired

ynamics effort, sharing knowledge with them as it accumulates

Follow up on HBOC Offer

Develop a contract with System Dynamics folks

Scoping Meeting in June.

Identify community business participation

Week long SYS Dynam meeting with the local Systems Team

Conduct community data analysis and costing for diabetes and CHF

Identification and contact with employers and community resources for support

Identification and contact with payors, national representatives for support in change in reimbursement model

Prospects for Grant Funding P2

Depression in Primary Care: Linking Clinical & System Strategies

http://www.wpic.pitt.edu/dppc/

 

Rewriting WA State medical reimbursement to support new models of care..

From: Anderson, Nancy, Dr. (MAA) [mailto:ANDERNA@dshs.wa.gov]

Sent: Monday, May 13, 2002 10:49 AM

To: Kevin Little

Cc: 'James W. Stout'

Subject: RE: [asthma] FW: [btscollege] Re: Asthma group visits

Medical Assistance (the Washington State Medicaid Administration) is in the process of writing billing instructions for group clinical visits, led by an MD or ARNP, that are specific for diabetes and asthma.

We've written various drafts of the instructions, but all include:

1. review of records/labs/etc by the clinician prior to the visit;

2. Group discussion devoted to a clinical issue;

3. Some question/answer time;

4. Routine review for all (most can be done in a group setting) and short individual visits as necessary

We will allow four one hour modules per year, which can be grouped together and billed as more than one module at one time. We will not allow billing for another e/m code the same day for the same diagnosis. We will allow those clients who have both diabetes and asthma to get clinical visits for each diagnosis (ie 8 one-hour visits a year, 4 for each disease). I'm hoping that we'll begin reimbursement June 1 (but with various bureaucratic issues, probably wouldn't make a bet). We also have a separate pilot project for asthma education with one clinical site, which is an individual contract. These visits are let by an asthma educator and are modeled after the diabetes education that we already reimburse.

Nancy Anderson MD MPH

Medical Epidemiologist

PO Box 45506

Olympia WA 98504-5506

360-725-1567 (v)

360-664-3884