Search for tag: "innovation"

The burning platform in health care is that the health care system really is not working. In fact, to even call it a system does an injustice to the word system. In the U.S. we spend perhaps 50% more per capita than anyone else in the world, and currently we have worse outcomes. So this is not a good situation when we're spending more than $3 trillion a year, 18% of our gross domestic product in an industry that is basically sick.

This is work I'm doing in collaboration with my colleague and friend, Michael Porter at Harvard Business School. Michael's a professor of strategy, and in fact, founded the field and he got interested in health care 10 to 15 years ago because he wondered, "How do you have a system like this sustain itself in such an inefficient way?" As he sort of threw it, he realized that the fundamentals for healthy competition, which ultimately is what drives value to consumers, does not exist in health care that we don't even agree on what goal of the system is.

So Michael has proposed, and I fully agree, that the basis for organizing the health care sector is around value, but we have a very specific definition of value is that for each medical condition, how do we improve the outcomes that are delivered and experienced by the patient and how do we lower the cost of delivering those outcomes, which doesn't seem revolutionary. But it is revolutionary because no one has defined the problem and the solution in that way. They've been all around this thing, how do we use checklists, how do we use lean and process improvement, how do we deliver better outcomes to patients and lower the cost of doing that?

So you think about a $3 trillion a year industry in the U.S. that doesn't know what its outcomes are and doesn't measure its cost, that explains a lot about the system that we have. And I got involved because I have developed a technology of how to measure cost and Michael's developed an approach on how to measure outcomes.

And then there's a third part, is when you have outcome measurements and you have cost measurements, you can reimburse providers in a very different way and right now, providers are reimbursed, in the U.S. mostly, by fee for service, and that rewards volume of stuff but not value, not good outcomes because the fees are independent of what outcomes get produced. And in fact, if you don't do a very good job and the patient has to come back for more work, you get more revenues. That's not a very good way of paying for health care.

So we're advocates of an approach that's beginning to come in called bundled payment reimbursement where you make a single payment to cover the treatment to entire medical condition. But we are actually doing it with [inaudible 00:03:04] flavor which is base it on, make the payment contingent on delivering good outcomes, which seems normal because if you buy a car and it doesn't work, you return it because it doesn't work. Every other industry that straight forward in health care, this is revolutionary. My role in this agenda primarily at this stage is the costing element and what I found does exist is that costs are not measured well in health care at the specific medical condition level.

Obviously, hospitals know how much they're spending. They can trace some of their spending to various clinical departments like orthopedics and cancer care, neurosurgery. They can't take the cost of that department level and drive it down to the patient level treating the patient for the clinical condition. I've helped to develop an approach called time-driven activity based costing which enables that assignment of expenses to be done well at the patient level. It just consists of really two types of two estimates and one of them is to understand the clinical pathway that is used to treat a patient with a medical condition.

What actually happens when the time they show up with a complaint until you diagnose it, treat it, through the surgery, the recovery and then the therapy and release them. What are all the clinical and administrative processes that are performed to get the patient through the entire cycle of care? And when we do that we try to find out at each process step, who is doing it. We can actually calculate how many minutes per year that a person or piece of equipment is available for patient work. That typically comes out to be 90 or 100,000 minutes a year. As you divide their annual expenses by their capacity, you get a cost per minute for every single individual.

And what's really fascinating about health care is the variation and cost rates. Until we have the MDs, whose cost rates could be somewhere between three and a half to six or eight dollars a minute. That would be typical rates, but you have a nurse, might be a dollar or a dollar and a half a minute and you have clinical assistants or scribes or receptionists for around $0.50 or $0.60 a minute. So you get this 10, 12 to 1 variation between the least highly and the most highly paid person which is really interesting because it says even if everybody is busy all the time and they're doing work, if you have a $5 a minute person doing something, that an 87 minute person could do equally well or slightly less efficiently, that's an inefficient use of the resources.

So there's an expression in medical care called have people work at the top of their license. But they don't really see the rationale or the economics behind it until you get to this caustic procedure. So combination of . . . they would take the process times for each person multiplied by their cost rate, cost per minute that tells you the cost of that person or the process step, and we just add it up across all the process steps over the whole cycle of care, and that tells you the total cost. This is not a quantum mechanics or genomic sequencing, it's really simple. What makes it difficult is just there's so many process steps.

So Michael and I are sitting there at the Harvard Business School four or five years ago and we realized, okay, this looks like this could work. But how do we get people other than the two of us to realize that this really could work in practice, there's a lot of good theories that don't work in practice. I said, well, the only way we're going to do this is to test it in practice and so we have to find pilot sites that are willing to try this out because we think we'll be able to create the change by demonstrating that it works. We want to work with leading providers. We're really excellent and they want to be better and they also want to prepare for the new environment where there will be fewer resources available to pay for health care.

And so the ones that are proactive and thinking ahead that they realize that this very forgiving fee for service environment will phase out over the next five years and they want to be ahead of the curve and see what can replace them. Currently, we're working with at least two dozen organizations and they're really distinguished organizations. They are leaders, the Boston-based hospitals and Yale Clinic and Cleveland Clinic, then about six or eight months ago, got contacted by Dr. Vivian Lee here at the University of Utah Health Center and Dr. Lee is a great visionary leader and those are the kinds of people I like working with.

So starting in January, I and my team came out here, we presented the ideas and we formed five teams to work on applying the time-driven ABC in three clinical areas and two support areas. We had the benefit of Dr. Lee, had already put into motion, with some terrific staff here, an emerging system called value-driven outcomes. We're getting outcome measurements very well at the clinical level as well as tracing starting to trace costs to the clinical level as well. And we had to just refine the costing module within that and to build upon this value driven outcomes approach that was being implemented.

It's been a great place to collaborate. We have the opportunity, the UHC has the opportunity maybe with some of our systems to really be one of the national leaders in implementing this value-based health care delivery approach. And so if we can use this as a shine, light, the example, this really can be done and it can deliver major improvements, and patients are better off and we're doing this at lower cost, people will see that this is really a successful way for transforming the way we deliver health care in the United States. There's a lot of skepticism in health care and they'll tell you 200 reasons why any innovation approach won't work and my role is to show it can work.

Interviewer: As a patient, you may have an idea for making your healthcare experiences better. Health care providers have them all the time. The trick is testing your idea and making it happen. That's the job of my guest Dr. Rachel Hess, director of a new entity at the University of Utah, called health systems innovation and research.

Announcer: Medical news and research from University Utah physicians and specials you can use for a happier and healthier life. You are listening to the Scope.

Interviewer: I am here today with Rachel Hess, the director of Health systems innovation and research at University of Utah health sciences. Welcome.

Dr. Hess: Thank you, it's nice to be here.

Interviewer: I am very happy to have you. So, how do you define health systems innovation and research?

Dr. Hess: I think health system innovation and research is really quite broad. It's an idea about changing the way that we think about our health system and making it part of the continuous learning process. So we take data from patients and data from the care that we provide and think about how we could be providing it better, and then try and implement those changes. One of the things that HSIR is really striving to do is service that bridge between traditional health services research and hospital operations.

Interviewer: So what are the primary goals of HSIR? I should mention to our listeners that health systems innovation research, of course, the acronym is HSIR.

Dr. Hess: Yes, it's much easier to say. The goals that we have set for HSIR are to let data define our questions, to test the questions, to test the ideas that allow us to answer the questions, to take those ideas that we are promising and generalize them to larger work and to allow the University of Utah to lead in stakeholder and data driven intervention. When we talk about stakeholders, we mean patients the community clinicians, payers and the whole health system and how do we take those who are involved in health care and allow them to help define what it is that we need to be thinking about.
Practically, we see what HSIR does as serve as a safe place for people who are both, traditional researchers and non-traditional researchers but just have a good idea to come and allow their idea to grow and incubate. People who can help you develop your idea, people who can help you around the regulatory issues of your idea, people who can help you implement your idea and people who can help you analyze the data.

Interviewer: This definition of an incubator, I think, is something that really resonates with a lot of people. Would you say that's a fair analogy for what you do?

Dr. Hess: Yeah. What we really want to be able to nurture is the person in the trenches who asks a question.

Interviewer: Can you give me an example of study that you are working on?

Dr. Hess: We know that only about 10% of people are quitting smoking at any one time and as a doctor, if you are counseling all of your patients who smoke to quit smoking, it can be kind of demoralizing and so what are the studies that we have done is we have tried to get patients to talk to their doctors about smoking. So you have taken a computerized version of a patient intake form, the piece of paper that you fill out when you go to the doctor, and allowed that to give patients feedback. The feedback said something along the lines of, "Smoking is not good for you, your doctor is really interested in helping you figure out if this is the right time to stop smoking and partnering with you to help you stop smoking." And we look to see whether or not, that made patients more likely to initiate discussions around smoking.
We did the same thing with physical activity and mental health and what we found in our small pilot study that is now going to a larger randomized control trial is that, patients who are given that feedback were more likely to initiate conversations with their doctors, both about smoking and about mental health related issues, which are two topics that are hard for patients to bring up and hard for doctors to bring up. And then, the doctors are able to use all of the great counseling tools that they have learned in medical school and through their residencies, to help the patients through those times.

Interviewer: You work with, you mentioned earlier, clinician investigator. Would you say they are your primary clients?

Dr. Hess: Our primary outreach client is clinicians who may not think of themselves as investigators and patients who may not think of themselves as investigators, who may come in with really great ideas on how to change health care as well.

Interviewer: Just a line those up, if I'm somebody who has a great idea, I could be a patient, a payer, anyone and I need some help and this is [inaudible 00:4:41] is that would like sort of a turnkey.

Dr. Hess: Yeah, that sort of where we want to be. We really envision ourselves as a place where somebody can bring an idea and we can help them develop that idea and help them figure out how to best implement and test that idea. So what resources do they need, in terms of data gathering, data analytics, regulatory oversights etcetera, and can we take that idea and move it from the idea stage to the small pilot stage to a larger pilot stage and then to a stage that may become a funded research project where they need help applying for the grant to get the proposal funded to do the larger study.
How do we help them take the data they have gathered and analyze it and put it together in a way that's shared, not only in the institution, but also nationally. So how can we be in that place where it's safe to come at any stage and get the help that you need. For some of our researchers that may be helped connecting with Clinicians and operational people who can help them implement. For some of our clinicians, it maybe connecting them with the research skills and teams that they need to help develop and test their ideas but we really view HSIR as a place that bridges those two groups and brings them together.

Interviewer: So Rachel, why do you think HSIR is needed and what motivates you to take this on?

Dr. Hess: There have been so many amazing interventions and ideas developed and tested that never make it into the clinical practice. We always talk about the diffusion of aspirin and it took how many years for the aspirin to diffuse in patients with heart disease, and that was a pill. When you talk about other interventions like behavioral interventions, diffusion of things like weight-loss to prevent diabetes, weight-loss and physical activity to prevent diabetes, still have not really been implemented in practice.
So there are a lot of things that we know from research that may be helpful, that we never get into practice. So that's a part of how do we diffuse those things in but beyond that, there are amazing things that are happening at singular institutions and that singular clinicians are doing. They are trying to deliver better care to their patients and those ideas rarely go beyond the individual clinician or the individual hospital, if we are luck. And part of what HSIR will do is create a space where those ideas can be expressed and validated and translated. So, to take us really to the space that is continuously learning health system.

Interviewer: And do you see publishing the results of a study as a fundamental component of that?

Dr. Hess: I think that publishing is a component of that. I would change the word publishing to dissemination and I think dissemination is a fundamental component of that. I think that how we disseminate knowledge right now in the traditional biomedical or the traditional academic environment through journal publications is probably not the most effective way to impact change.

Interviewer: We often hear in the news, a new study was published in the journal Lancet and so now, we are going to be doing something with managing blood pressure but it sounds like there are other ways that patients can benefit from new ideas and technologies without necessarily publishing being a part of it.

Dr. Hess: There is a lot of good work that doesn't make it into Lancet, New England journal, JAMA, Annals, etcetera and that doesn't get picked up by the news outlets. Once the news outlets pick it up, it's almost that the journal was the conduit to get the news outlets to pay attention to it. But the news outlets are almost more important than disseminating the work to the general public and in a lot of cases, to the clinicians out there also because we can read everything that's coming out and we hear about it on the news sometimes too and then go learn more. But we are going to need to find new creative ways to disseminate this information and I think some of those are through non-traditional media or social media like Twitter and blogs and things like The Scope radio program that may be places that people can hear about things and then go read more.

Announcer: We are your daily dose of science, conversation, medicines. This is the Scope, University of Utah Health Scientist Radio.

I think Americans understand that we have to have change. I think that until it begins or however when it becomes personal to them, like any change, it begins to be more difficult. But I think that American's understand that the system is going to change and they are buckling their chin strap to see how it will affect them.

The areas that I am focused on now are essentially how can we drive more quickly? The concept of measuring value not volume and that isn't controversial any longer, but the implementation of it is and does begin to drive a lot of change that people are uncomfortable with.

The parable of buses, taxis, and limos basically says that there is a lot of ways to get from point A to point B and after all, what we are after is transportation in healthcare. After all, what we're looking for is good, quality care. The setting in which we get it, how fancy it is or how comfortable it is, in the context of convenience, it may be that some people will say, "I'm prepared to have a narrower network of choices for a lower premium." We've seen that begin to happen already. Those are choices that consumers can make. They can make them in any other area, and they can make them in healthcare as well.

I think that big change to the future is we are going to start to value both of those, cost and quality. As opposed to simply having access to unlimited amounts of care.

There are four basic entities or types of entities that I think are making competitive entries in the market. They are obviously hospital driven, doctor driven, insurance company driven, and a new group that I call strategic aggregators. These are unlikely entries into the market with people like Walgreens and CVS who have footprints on almost every corner and are beginning to turn parts of their retail stores into care centers. And I think we will begin to see them play much more pronounced and perhaps prominent role.

All four of those types of entities are looking to become what I refer to as a general contractor in medicine. I think that's the struggle that's happening.

We are now moving into a period where care is going to have to be much better coordinated and the question becomes in a coordinated environment, who is the general contractor and who is the sub-contractor and who is bearing the risk? And that's being redefined in every medical market in the country. No one has all of the competencies that are required.

If we look back 25 years and we looked at industries like the restaurant business or the hotel business, there were lots of independent hotels and restaurants. And now we have Marriot and Hilton and brands we know. I think health care will always be local. But I do think we will begin to see health care, particularly primary care, begin to consolidate into a series of brands that we're better familiar with and will compete on a more national or regional basis.

I'm probably more optimistic today that we're actually getting a handle on the problems of health care than I have been for some time. Because hard things are beginning to happen and people are having to make choices and they're working with certainty to get a handle on their costs. And that's not easy. It's hard. But hard things are happening and because hard things are beginning to happen my optimism goes up.