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Prognosis on Electronic Medical Records: The Long Slog to Come
On July 13, 2010, HHS released final rules telling providers of care how to demonstrate the “meaningful use” of electronic medical records in order to be eligible for incentives starting in 2011. By 2015, most providers who don’t adopt electronic medical records will face penalties. The originally proposed rules were considered too rigid by many, and would have made it too difficult for hospitals and physicians to earn incentives. The final rules do give more flexibility than the initial rules published in January: the threshold to earn incentives is set somewhat lower and the bar is not an “all or nothing cliff.”
But even though the final rules are an improvement over the initial proposals, the provider community remains skeptical that the incentives – or penalties – in the rules are sufficient to entice a large number of providers to convert to electronic records. Most are predicting the dissemination will not be as fast or as deep as many would hope.
There is widespread support for the concept that electronic records can improve care. Global measures of the quality and safety of medical care show the potential impact of electronic records: countries with more extensive electronic records have better overall quality of care than the United States.
Yet, the data are also pretty clear about changing practice structure: it is hard and won’t happen overnight. Indeed, we already have data to say that the movement towards electronic records is going to be slow and somewhat painful. A new study from the Center for Studying Health System Change (CHSC) tracks the use of e-prescribing and shows the scope of the problem.
Some consider e-prescribing an entry level component of a full electronic medical record; many groups and individuals have been promoting the use of e-prescribing systems for years. Indeed, vendors have all but given away these systems to encourage their use by physicians. But despite these efforts, the CHSC study shows that only two in five physicians in office-based ambulatory practice reported that IT was available in their practice to write prescriptions in 2008. And, I think, most critically, the authors reported that physicians who had access to e-prescribing did not necessarily use it routinely. Notably, about a quarter of those physicians reported using the technology “occasionally” or “not at all.” All told, in 2008, somewhat less than one third of ambulatory physician practices both had and used IT for prescription drugs.
The CHSC study was completed prior to the advent of federal financial incentives for the use of electronic records. It is almost certain that the numbers will improve as a result of the incentives and impending penalties. Even so, the CHSC findings are instructive about the challenges the implementation of full blown EMR strategies are likely to face.
The reality is: human behavior is difficult to change. And, though business schools have spent years developing change management structures for corporations, these methods are – at best – nascent in most physician practices in this country.
It is terrific that the federal government is providing technical assistance to practices to help them with IT implementation: that will certainly help with their success. But, we must be realistic about what can be accomplished and how long it will take. I do believe we will get there. But, this is truly a long distance race, not a sprint.
Physicians: To employ or not to employ – that is the question!
While my personal thoughts frequently center around issues such as "being,” on a professional level I have probably given more thought to the issue of physician employment than any other.
I am old enough to recall when an employed physician was actually an oddity. During my many years working on the provider side of the business, I experienced the rush to employ physicians (by hospitals in the 80s) that was akin to the gold rush. Many advisers and consultants, including think tanks like the Healthcare Advisory Board, suggested the real key to success was going to be physician employment.
You may recall this also ushered in the era of "physician practice management” companies that were going to hit it rich in the physician employment/management business; some, like Phycor, made it all the way to Wall Street.
And of course, we all remember hospitals that experienced devastating losses by acquiring physician practices. Subsequently, many hospitals and health systems reversed course – like ships heading for icebergs – and dumped all or many of their employed practices.
Throughout this time, reams of literature have been written on the pros and cons of the private practice of medicine. Many articles have extolled the virtues of "The Staff Model.” In addition, numerous “physician relationship” models have been published and promoted, claiming to be the Holy Grail of physician compensation and management.
When considering the topic of physician employment, the obvious question arises: By whom? Earlier I mentioned hospitals and physician management companies, but they are only two of an array of options. Foundations, for-profit companies, physician organizations, and multi-specialty groups are just a few other possibilities.
The topic of physician employment is once again front and center, and it continues to pique my interest as an insurance executive due to the implications for provider reimbursement models and physician/provider relationship issues. It certainly has bearing on current hot topics, such as patient centered medical home (PCMH), accountable care organizations (ACOs), etc. This issue has also become personal to me now that I have children who are physicians.
At the present time, it is pretty clear that many – if not most – hospitals have once again embarked upon aggressive plans to employ physicians. Interestingly, a few never stopped, particularly those who have based their systems on the Staff Model and Foundation Model. I have also talked with some hospitals who are not ramping up their employment of physicians and who still believe strongly in a pure private practice model.
Many articles in the literature indicate that recent healthcare reform legislation is likely to fuel consolidation in the provider community. Increased physician employment by hospitals and health systems would seem to be a likely outcome.
One of the big questions I have is: What has changed since the last time hospitals employed physicians that is fueling the current drive to employ physicians? Recent articles suggest the employment model will be "different" this time, yet, as I speak to hospital executives, they inform me that the losses incurred by employed physicians are similar to what I saw/experienced in the 1980s (approximately $20-$120K per year per employed physician).
I have also seen reports in the literature that each physician has the potential to bring $1-$3 million dollars in referral revenue to a hospital. Perhaps this is a motivation for employment. Yet, this logic only holds up if one is able to move business from competitors and produce adequate margin on that business to offset total cost. This logic didn't seem to work out in the 1980s. It certainly doesn't make sense if you are already the recipient of this business, except from a defensive posture.
Then there is the issue of independence and productivity. I have heard arguments on both sides of this issue from numerous physicians. It is a tough call and probably a very individual matter whether an independent or employed physician is more productive. I have personally seen proprietary data, during my days on the provider side, which demonstrated that employed physicians definitely demonstrated a higher level of loyalty to their employer than independent physicians.
It does seem clear that current medical school graduates have less of an appetite for setting up a private practice. This could be a generational or cultural/lifestyle issue. It could also be a function of debt load upon graduation, or a variety of other factors.
My colleague Tom Simmer, M.D. and I have had a number of provocative discussions on this topic. Based upon those discussions, and my utmost respect for Dr. Simmer's opinion, I have come to believe that, in spite of the current trend to employ physicians, private practice physicians will continue to survive and thrive alongside their employed colleagues, at least during our lifetime.
I would love to hear your opinion on this evolving topic!
Bob Milewski is senior vice president of Contracting and Hospital Relations for Blue Cross Blue Shield of Michigan and a member of CHRT's board of directors.
Health Reform: The Early Days
Early reviews are in and they are favorable! Public opinion polls show support for the Affordable Care Act (ACA) creeping up to 48 percent. All of that is good news, and a well-deserved commentary on health reform: States and the U.S. Department of Health and Human Services have been moving quickly to put in place the most immediate requirements of the law, and communities, providers, and others are stepping up to participate in health reform opportunities (e.g., funding for more primary care training slots through the Prevention and Public Health Fund). In addition, states have announced the beginnings of temporary high risk pools, and the federal government has debuted a new website - www.healthcare.gov - to help consumers in every state navigate their health care options.
These achievements are quite impressive. The work produced to date has been of good quality and has moved quickly in accordance with the commitments made in the ACA. And all of this has happened without a Medicare/Medicaid director in place – which will now change given President Obama’s recess appointment of Don Berwick.
These early steps are critical: their importance cannot be over-estimated. Indeed, if one looks closely at the dialog around health reform, it seems clear that the tone and expectations around the ACA have changed in a significant way: it’s beginning to feel like the ACA (in its broadest principles at least) will survive.
While the lawsuits challenging the ACA continue (testimony was given in the first lawsuit in Virginia on July 1, and hearings will begin in Michigan and California later this month) and are likely to end up in the Supreme Court, the work of implementation goes on. The activity around the implementation of health reform is building a sense of permanency around the ACA. Even states who are suing to stop the law are simultaneously moving forward to take advantage of many of its provisions.
Advocates bemoan the fact that the major coverage elements don’t go into effect until 2014, and many feel without those elements, most people won’t really see how health reform benefits them. But as health reform is unfolding, and with everything that is happening before 2014, it is now apparent that people all around the country will feel the effects of health reform long before the major coverage elements go into effect. And even if court challenges are successful, unwinding health reform will be difficult at best. Moving a bureaucracy to implement new things is tremendously difficult (especially when dealing with one sixth of the economy): reversing directions is even harder.
Those who want to see this law succeed might now see real hope for at least key elements of the law to survive. And while the individual mandate is the piece of the law with the least public support and the greatest risk in the courts, there is much more in health reform to improve the system beyond the individual mandate.
Now, if just a little more effort could be put into helping the public at the grass roots level understand just what health reform really is and how it benefits them, maybe even the individual mandate will survive…
The Berwick Confirmation and Irrationality
The confirmation process for Don Berwick as President Obama’s nominee to be director of the Center for Medicare and Medicaid Services within the Department of Health and Human Services should be a most distressing sight to anyone who has spent their careers in health policy – or who even has a passing interest in the policies and politics of health care. And, if Dr. Berwick’s critics prevail, all citizens should be concerned about the message that would send about health care in this country.
It was bad enough last summer when provisions in the health reform bill that would have supported patients, families and clinicians with help they desperately need at the end of life got characterized as “death panels.” Those debates raised unnecessary fears and ended up diluting the end of life provisions in the final law such that families are getting less help than they might have. But, those debates did not go to the underlying and sweeping issues in health care. The current critiques of Dr. Berwick do. The Congressional critics of Berwick attack fundamental issues with a particular focus on how we use resources in this country. The outcome of this debate will have an impact on all citizens that will go far beyond health care.
Dr. Berwick has been “accused” of embracing the British system of health care. Heaven forbid that he should have good things to say about a system that has better health outcomes than ours on a population basis and at significantly lower cost (see the latest Commonwealth Fund report for its seven country comparison). The critics have said that Dr. Berwick’s embrace of the British system means that he is a big fan of another dreaded concept, “rationing.”
Dr. Berwick and most health policy analysts actually don’t disagree with that point, but note that rationing goes on every day in the current health care system in America – we just don’t make it very explicit – and that in the end, some form of rationing is necessary because we have limited resources and they must be used wisely so that multiple public needs can be served.
Many analysts have pointed out that the American health care system today rations care based on ability to pay. I actually think a more comparable situation to the British approach can be found within the health plans of those who are already insured. That is, I don’t know any health plan that pays for every procedure that has ever been invented. Rather, all health plans make choices about what to cover and what not to cover. Some couch those choices in a phrase in employee plan information called “medically necessary”, i.e. plans say they will only pay for what is medically necessary leaving the details of that definition up to the health plan itself. Some give a specific list of procedures that are excluded. But, none pay for everything.
This is rationing by any definition being used in Congress today: it’s just a less transparent, private sector approach to rationing in contrast to the British system that actually has a public entity that makes explicit decisions along these lines and that allows public debate of the pros and cons of these decisions.
Taking the arguments of the opponents of Dr. Berwick to their logical extension, they are either saying we should simply pay for as much health care as anyone, anywhere in the country wants (hmm, wasn’t there an argument that the Affordable Care Act didn’t have enough cost control in it?) or that it’s better to make these kinds of decisions through the inconsistent, somewhat ad hoc process that we have in place today. It is hard to draw any other conclusions from their arguments.
Over the year, Dr. Berwick has said things such as that in America we have a “dangerous, toxic and expensive assumption that more is better.” And, he has made clear his (and most other health care analysts’) belief that we can cut health care spending without harming patients because there is so much misspending in the current system. As a result, he has urged practitioners do things such as “reduce the use of unwanted and ineffective medical procedures at the end of life.” So, if this is the kind of “rationing” the critics disagree with, well, to do anything else would be plain…irrational.
The Flap About the Dartmouth Atlas
Earlier in June, the New York Times ran an article by Adleson and Reed questioning the findings in the Dartmouth Atlas. Jack Wennberg and colleagues have been working in this field and documenting small area variation in health care since the 1970s. However, the work was not much recognized outside of academic and health care analytic circles until the start of the discussion on national health reform. In a very short period of time, the analysis went from being in the sole domain of providers and policy wonks (hmm, could that be me?) to being on the tip of the tongue of policy makers in Congress and the White House. Tracing the trajectory of this research from relative obscurity to the New York Times article provides an interesting insight into both the policy making process and the risks and opportunities inherent in trying to translate research into public policy.
The basic concept behind small area variation analysis is that health care utilization differs by community in ways that cannot be fully explained by the characteristics and medical need of the population being served in that community. Stated in this way, I think there are few who would actually disagree with that observation. On this point, the data are strong and have been consistent for the more than 40 years history of this kind of analysis. While the methodology has changed over time to look at these trends, the simple fact of unexplained variation is a robust concept. However, taking that observation and deciding what to do about it is an entirely different issue. To craft an intervention that tries to reduce unexplained variation, there must be a theory behind what causes the variation – and therein lies the rub.
There are many different theories to explain why there is so much regional variation in health care. Some believe that the variation is principally driven by the supply of providers (for those of us who went to public health school some time ago, the old Milton Roemer law: “a built bed is a filled bed is a billed bed”). Some believe that the variation is a result of practice patterns that have grown up regionally over time combined with a lack of clarity in the evidence base for treatments. Some argue that the variation has to do with true differences in patient characteristics that aren’t accounted for in the methodology. And, some contend that the way care is organized and delivered accounts for these differences.
While these explanations are not mutually exclusive (and many think there are elements of all of them at work), the explanation one believes is most important will lead to different ways to address the issue. And, beyond that, there is an underlying difference of viewpoint as to whether such variation is good or bad, i.e. whether areas with higher use rates are providing better or worse care and producing better or worse outcomes. For some discussion of this issue, it is useful to look at Dartmouth’s response to the New York Times article.
What happened with these data, however, is instructive and illustrative of the challenges inherent in translating research into policy. When Congress started paying attention to the data and seeing it as an opportunity to help with the cost savings needed to make health reform work – surprise, surprise –the “what to do about it” question became over simplified and the answers started a debate between high spending and low spending states about who should get more of the Medicare pie. That high profile debate resulted in the research itself becoming open to more and more scrutiny and critique and to the ultimate challenge posed in the New York Times article.
In the end, there probably isn’t one explanation for the variation or one set of solutions. The data included in the Dartmouth Atlas and in other analyses like this are a starting point for understanding where the opportunities are for quality and cost improvement – more analysis is really needed to get behind the numbers to understand the dynamics that lead to them. What would be most unfortunate in all of this debate, however, would be to lose sight of the fact that the degree of regional variation in how medical care services are provided in this country is enormous and much of it cannot be easily explained by differences in patient characteristics. The data in the Dartmouth Atlas are important indicators of opportunities to reduce health care spending in this country, and while there can be debate about how much and in what ways, the data must be taken seriously.
Cover Michigan 2010
Today, we are releasing our 2010 report on health care coverage in Michigan. This report includes comprehensive data on the uninsured, publicly, privately insured and the safety net. In addition, we have included a final chapter on what could be the impact of health reform on coverage in Michigan. The 2010 report principally includes data from 2007/8, the most recently available comprehensive data on health care coverage in the U.S. and Michigan.
Perhaps not surprisingly, the picture of health care coverage in our state in 2007/8 looks considerably worse than it did in 2005/6. The degree of change in a negative direction is greater than we expected and most concerning. For example:
• While still better than the national average, Michigan’s uninsured increased significantly between 2005/6 and 2007/8. Michigan now ranks 16th lowest in the country in terms of the percent of the State’s population who are uninsured compared to 10th lowest in 2005/6 – that’s a concerning change in ranking in just one year.
• Medicaid expenditures continued to grow representing 22.2 percent of the total state budget in 2008, a considerable increase from the 18.9 percent it represented in 1999. Michigan ranked 16th highest in terms of state expenditures for Medicaid – a big change from 2007 when Michigan ranked 27th highest.
• The rise in the uninsured and publicly insured has been a direct result of the continued decline in private coverage in the state, going from 77.5 percent of the state’s population in 2003/4 to 74 percent in 2007/8. And for those with coverage, there has been a significant increase over the past several years in the share of premiums individuals are paying.
The report also notes the strain on the safety net these changes are taking – with more than $2 billion in uncompensated care now being provided by hospitals and safety net providers being challenged to care for all those in need.
We do project a very positive impact on these trends due to health reform. Indeed, if everyone who becomes eligible for Medicaid enrolls and everyone who is mandated to have private coverage, purchases that coverage, the number of uninsured in the state could go from more than 1 million in 2007/8 to less than 150,000 in 2014, mostly undocumented immigrants. And many will likely benefit from the subsidies and tax credits included in health reform. But, the most significant health reform changes won’t take effect until 2014 – 4 years from now. And, when we look at these data again for what has happened in 2009/2010, the trends are likely to be worse.
But given that the most significant changes from health reform won’t take effect until 2014 (and 2009/10 is likely to look worse than 2007/8), should we all just hunker down until then? Well, no. There are two charts in the report that I think are very significant and give us both hope and a challenge. If you look at nothing else in the report, take a look at the charts on pages 47 and 115 (ok, not a test to see if you read it!). On page 47, we noted that the state peaked in terms of enrollment in Medicaid in 2005 – a time when Michigan had a very robust outreach effort designed to get kids enrolled. At that time we had more than 55,000 kids enrolled in MiChild. The number has now dropped to less than 44,000 – not because the need or eligibility have changed but because there is no longer the outreach program as a result of state budget challenges.
Similarly, our data on page 115 show that almost 16 percent of those who are currently uninsured – more than 165,000 people are Medicaid eligible today under the current eligibility rules. So, these are our opportunities and our challenge: we can get many more people enrolled in coverage if we want right now – we don’t have to wait until 2014.
And, lest we get too overwhelmed with the negative, there is one piece of really good news in the report: again this year, Michigan health insurance premiums are less than the US average. In 2008, Michigan family premiums averaged $11,300, $1,000 per person less than the U.S. average of $12,300. Now, that is something to build on!
Smorgasbord Anyone?
The recently passed “Patient Protection and Affordable Care Act” a/k/a “health care reform” is a monumental piece of legislation, both literally and figuratively. Despite its supposed intent to “reform” the health care system, however, it is quite tepid on reform and very aggressive on enhancing coverage.
The legislation contains a virtual smorgasbord of programs, directives, initiatives, instructions, orders, regulations, requirements, recommendations, exchanges, options, incentives, rewards, pilots, demonstration projects, commissions, task forces, centers, institutes, fees, grants, taxes, tax credits, and mandates. Unfortunately, very few of these components address, in any serious manner, what many clearly feel is the most critical problem of our current health care “non-system”: the ability to constrain the unrelenting and unsustainable increase in the cost of care.
For example, the chance to implement meaningful tort reform, substantially revise the provider reimbursement structure to reward value (quality) instead of productivity (quantity), improve end-of-life care, or link cost-effective analysis with coverage decisions was either relegated to small pilot programs (malpractice and reimbursement) or ultimately dismissed because of a lack of political courage (cost-effective coverage decisions and end-of-life care). The end result is that the legislation largely addresses coverage expansion and essentially ignores the underlying structural cost drivers. To put it more succinctly, the bill “dumps’ over 30 million newly insured members into a highly dysfunctional, inefficient, fragmented, and extremely costly health care non-system.
Notwithstanding the rhetoric of the bill’s partisan supporters that it will reduce health care costs (by “eliminating waste, fraud and abuse”!) and the federal deficit (by “bending the cost curve”!), the final result will inevitably be an acceleration and heightening of an already out-of-control cost issue. I would suggest that anyone who thinks otherwise probably needs an urgent head CT scan, immediate detoxification or an emergency psychiatric referral (or perhaps all three!). All of these services by the way will be readily available, at little or no cost and with little or no scrutiny, under a poorly designed, heavily regulated, quasi-government run, plan.
What is unfortunate about this situation is that our “leaders” had a real opportunity to truly “reform” (revolutionize?) the health care system but that chance is probably now lost. It is highly unlikely that any substantial or meaningful efforts or revisions along with these lines will be forthcoming in the near future. Instead, the focus will be on establishing the detailed rules and regulations that will govern the existing legislation. Attention will therefore be on the trees instead of the forest.
Smorgasbord sandwiches often taste good initially but when completely digested, the full effects become readily apparent. Under the circumstances, consulting your local gastroenterologist would seem to be a prudent next step.
Guest blogger Douglas R. Woll, M.D. recently retired from his position as senior vice president and chief medical officer for Blue Care Network of Michigan, the HMO subsidiary of Blue Cross Blue Shield of Michigan. Prior to joining the Blues in 1998, Woll spent almost a decade at SelectCare, where he served as senior vice president and chief medical officer. He served as a senior staff physician at Henry Ford Hospital from 1980 through 1989. Woll is certified by the American Board of Internal Medicine, and was elected a fellow of the American College of Physicians in 1998. He is involved with several professional organizations, including the Quality Committee of America's Health Insurance Plans.
What I wish she had said… The challenge of really communicating about health care reform
The Detroit Regional Chamber of Commerce held its annual policy conference on Mackinac Island this past week. Health care reform was a topic of great interest to many of the attendees. In general, this group of 1,100 or so business leaders was either agnostic about the Patient Protection and Affordable Care Act or negative on it. Few had much knowledge of the details or clarity on what to expect – there was much confusion and an overarching view that there was just “too much government” in it.
Kathleen Sibelius, Secretary of U.S. Department of Health and Human Services, was the keynote speaker on Friday morning, June 4. This was a golden opportunity to really connect on the value of the Act to this largely skeptical but very influential audience.
So, did she? Unfortunately, no. What she did at the Mackinac conference is representative of what has been happening since health reform was passed into law earlier this year and why there has been no positive “bounce” for that passage. The problem with how communication has gone on health reform isn’t just the fact that there have been a lot of other critical issues since its passage – everything from the Gulf oil spill to the employment numbers – it’s really about a lack of a cohesive message that connects with consumers, business leaders, providers, and state policy makers about what health reform really is and what it can do for them.
Secretary Sibelius is clearly very competent and extremely knowledgeable. She demonstrated all of that on Mackinac Island. But, what she did in her speech was to describe the Act in its parts. By 15 minutes into her 45 minute talk (she took no questions), the audience had checked out – with most on their Blackberrys or reading the newspaper. She gave a list of some of the things in the Act and tried to say that it was important because otherwise, businesses in this country would not be competitive. But, she gave no overarching vision of the Act – no emotional punch about why it’s important and what will look different after it is fully implemented. And, she relied on a statement that everyone in Washington seems to think resonates outside the beltway: she talked about her latest trip to the Mayo clinic – something that actually doesn’t help many people relate to the promise of this law.
Why is it so hard to communicate the positives that are in this Act? Is it because it is 1,000 pages long? Is it because since it is dealing with one sixth of the economy, there are many different sections and aspects to it? Is it because there are so many details that the focus becomes on those rather than the whole?
It’s probably all of those things and also the fact that those in Washington have been so immersed in the ins and outs of the specifics, that they have lost sight of the fact that most of the country still just doesn’t get the over-arching premise of the Act.
The audience in Mackinac needed to hear this: the Act will reduce the number of uninsured – significantly. And, that’s important because the health of our citizens and productivity of our country is affected by not having insurance. The Act will provide financial support for millions of businesses in the country (small businesses – the engine of growth in this economy) to provide health insurance to their workers – thus, helping them attract and retain good employees, and immediately helping them to reduce their costs. Groups (employers and labor unions) that provide coverage to early retirees will get financial support to do so. The Act will help fix the broken individual market – making sure those who are sick are not excluded from coverage and helping to even out the risks and costs of coverage. Both individuals and businesses will be able to make more informed health insurance purchasing decisions because of this Act. And, the government role in all of these areas is essential to make them work. There are only limited ways to get to essentially universal coverage and there are problems and benefits associated with all of them. The approach embedded in PL 111-148 is actually one that was previously favored most by conservatives and is, in important ways the one that includes the least intrusive role for government. The Act includes a significant amount of state and local control and leaves many crucial decisions to providers of care, community groups, and state policy makers. And, the Act lays the ground work towards improving our health status, our health care work force, and the quality and efficiency of our medical care system in fundamental ways.
Many of those points were there in Secretary Sibelius’ speech – but they were there as trees and not the forest. She needed to give that big picture – and then fill it in some to help people see more concretely how the Act will benefit each segment represented in the room – business, consumers, state leaders and Michigan overall. And, then, she needed to take questions.
Creating Focus and Building on the Opportunity of Health Reform
As I’ve said in past posts, health care reform is much more about insurance reform of the health insurance system than it is about real and fundamental change to the health care delivery or public health systems (see “The Case of the Missing $115 Billion"). The bulk of the dollars included in the Patient Protection and Affordable Care Act (PPACA) go toward expanding coverage rather than improving the delivery system.
But the PPACA includes many good concepts that would – if funded – strengthen clinical and public health outcomes. To capitalize on these opportunities, however, it will be essential for those who care about these issues to be actively engaged at the federal, state and local levels.
On May 25, 2010, our organization released a policy brief to help guide advocates, consumers and others to take advantage of those opportunities. Those opportunities for state and local action fall into two broad categories:
- Appropriations. At the federal level, it is essential to address the issue of funding for provisions in the Act that are authorized but not appropriated. Our Congressional delegation and others in Congress need to hear that these ideas are important and have strong local support.
- State and local approaches to implementation. At the state and local levels, there are many choices to make as the Act is implemented, and many opportunities for providers, advocates and others to come together to improve the quality, efficiency, and safety of the health care system. Citizens’ voices will be important to define the best way to set up things like insurance exchanges, select approaches to Medicaid expansion, and pursue demonstration projects at the state and local level.
What is important to understand about these opportunities, however, is that they will only be available to the extent that groups and individuals come together to develop a collective view on what should be done. Groups are so much more effective in Washington or Lansing when they speak with a common voice rather than advocate for their own individual ideas or agendas.
Michigan has both a special challenge and opportunity in that regard. Over the next several months, the executive branch in state government will go through wholesale change as the Granholm administration leaves office and a new administration comes in. All of the decisions being made now could be fundamentally changed by a new administration. In addition, virtually the entire Michigan Senate will be changing in January. This inevitable change in leadership makes it even more important in Michigan than in most other states for voluntary groups to come together to help lay the ground work for health reform.
For years in Michigan, we were told that we did not get more funding for federally qualified health centers (FQHCs) because we had no common vision and too many groups competing against each other. FQHCs are now coming together with a shared voice: are other groups ready to do the same?
The Health Care Industry in Michigan: Staying on the Open Road
When I first came to Michigan from Indiana a year ago, I knew I was coming to a special state for health care.
Impressively, hospitals across Michigan have topped the national charts for years when it comes to providing high-quality health care. And compared with most states, Michigan has a long history of innovative pharmaceutical and medical research, excellent private insurance coverage for workers and a strong medical safety net for the poor.
Now, as we face known and unknown implications of federal health care reform, an increasingly competitive statewide environment and ongoing economic challenges, we also stand at an important fork in the road, where the path we choose will determine the future of our health care institutions, as well as the health of our citizens and of our broader state economy.
One direction will take us down an open road, wide enough for healthy industry competition to co-exist with collaboration and partnerships that leverage the extraordinary knowledge and expertise of Michigan’s health care community. This direction has the potential to lead to cost containment while preserving our ability to serve Michiganders with the excellent care they deserve.
Another direction could force our hospitals and other providers down a road toward intense competition that would move us away from why most of us entered health care in the first place – to discover and implement the science and practices that make people and communities healthier. That path could also compromise our ability to reinvent and reinvigorate Michigan.
In many important ways, we’ve already started down the open road.
Hospitals and doctors’ groups across the state are working together to improve the efficiency, quality and safety of the care they provide, while containing the growth of health care costs. In addition, they are finding ways to make sure patients have access to as much care as possible closer to home so they only need to travel to receive the most specialized care.
For instance, dozens of hospitals across the state have united in the shared interest of improving the care of patients with clogged arteries through the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. By sharing data and best practices – together – we’ve prevented needless complications in thousands of patients and saved millions of dollars. We’re engaged in the same type of statewide collaborative work with initiatives that focus on everything from stroke to cancer to surgery.
Similar collaborations and sharing of best practices are happening in doctors’ offices statewide. Thousands of physicians are taking part in the Physician Group Incentive Program, a cooperative effort to improve the quality of the care they provide through their group practices. One example of the power of these partnerships is the savings of $29 million realized through specific steps to increase the use of generic drugs.
In support of this effort, University of Michigan teams have been training participating physicians in the “lean thinking” approach that many industries have used to streamline their manufacturing processes. We’re using a “lean” approach at the U-M Health System with great results and are excited to share this methodology with our partners across the state so that they can implement systematic changes that benefit their practices and organization.
We have to work hard to stay on a course of partnerships and overall improvement of health care delivery in Michigan. We cannot lose site of the benefits of collaboration and cooperation, especially as the forces of health care shift and especially as our citizens continue to need and deserve the best care.
Hospitals, health systems and physician groups have a choice to make about which path we take. Let’s make the right one.
Ora Hirsch Pescovitz, M.D., is the Executive Vice President for Medical Affairs at the University of Michigan and CEO of the U-M Health System.
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