Delivery of Care

Shared savings, shared stories – but poor messaging

How does the patient experience change in Rhode Island’s health care reform evolution?

PHOTO BY Richard Asinof

Blue Cross & Blue Shield of Rhode Island President and CEO Peter Andruszkiewicz, second from right, talks with Care New England President and CEO Dennis D. Keefe, Lt. Gov. Elizabeth H. Roberts, Sen. Sheldon Whitehouse, Dr. Deidre Gifford, Dr. Thomas Bledsoe of the R.I. Chronic Care Sustainability Initiative and Dr. G. Alan Kurose, president and CEO of Coastal Medical.

By Richard Asinof
Posted 12/9/13
The outcomes of health care reform, rather than the mechanics of signing up for a health insurance card, often get lost in translation. Here in Rhode Island, where the health care reform “evolution” is moving ahead, the news media has done a "mediocre at best" job in reporting on the transformation. As Whitehouse’s briefing demonstrated, it’s a complex story to tell, with lots of changes for the better taking place. But advocates themselves have often done “a crummy job” talking about it.
There were some conspicuous health care folks missing in action. Why was Lifespan not at the table? And, why was Neighborhood Health Plan absent? And, why no participation from any community health care centers? It was, however, not that difficult to figure out why UnitedHealthcare was not at the table, given their abrupt cancellation of working arrangements with numerous surgeons and practices under their Medicare Advantage plans.
The use of analytics to develop measures for population health management, the metrics for global payments, continues to be a little understood story for something that will be a linchpin for future reimbursement strategies.
The other development that looms large is the way that engaged patients and engaged communities, using their own data-driven tools and social media networks, are changing the dialogue, attempting to put “healthy” back into health care. From the R.I. Alliance for Healthy Homes to the PANS-PANDAS Parents Network to the community of medical experts such as The Miriam Hospital cardiologist Dr. Barbara Roberts, unafraid to speak out against the new, misguided (in her opinion) statin guidelines, the “father or mother knows best” doesn’t work anymore.

EAST PROVIDENCE – In an impromptu press briefing arranged by Sen. Sheldon Whitehouse on Dec. 2, movers and shakers in Rhode Island’s health care reform “evolution” efforts gathered around a small table in the fourth-floor lunchroom at the Coastal Medical building on Warren Avenue to share their “success” stories.

There to offer proof positive were Lt. Gov. Elizabeth H. Roberts, Care New England President and CEO Dennis D. Keefe, R.I. Chronic Care Sustainability Initiative Director Debra Hurwitz, Rhode Island Quality Institute President and CEO Laura Adams, Blue Cross & Blue Shield of Rhode Island President and CEO Peter Andruszkiewicz, and Dr. G. Alan Kurose, president and CEO of Coastal Medical.

“It’s great to be here in this luxurious office room,” quipped Roberts, drawing laughs. “I see this as a good sign that the investment is going on where the patients are.”

The ad hoc story telling, conducted for the apparent benefit of the news media (it wasn’t for the participants), demonstrated the difficulty health care reform advocates have had in presenting clear, concise messaging about a complex topic not well understood by the public – or the news media.

Whitehouse did attempt to frame what Rhode Island was doing within the global context of health care reform – showing charts of the U.S.’s “ridiculously” high costs and low performance – “mediocre at best,” as Whitehouse termed it – for health care and life expectancy.

“We have a lot to be proud of in Rhode Island, and I wanted to showcase that work,” Whitehouse said, explaining the purpose of the hastily assembled briefing, at a time when health care reform efforts are under attack nationally.

The news media (save for ConvergenceRI and Channel 10) were 20-30 minutes late in arriving, and, not surprisingly, “missed” the messaging. The reporters seemed much more interested in capturing Whitehouse’s comments on the problematic national rollout of the Affordable Care Act than on learning about what exactly was happening in Rhode Island.

In response to a question by a Providence Journal reporter, Whitehouse assured her that the Affordable Care Act was not going to fade away. The show-and-tell – with an emphasis of telling – did not translate into more than a blip on the 24/7 breaking news treadmill.

In response to a question from ConvergenceRI, Andruszkiewicz acknowledged that, for the most part, that the advocates of health care reform had done “a crummy job” on getting the message out to people about the positive impacts of health care reform in Rhode Island.

Nuggets of bronze, silver, gold and platinum
There were, however, plenty of bronze, silver, gold and platinum nuggets in the conversation, if you were listening.

Keefe announced that Care New England was going to roll out new global payment initiatives, to move away from the perverse incentives of fee-for-service. They included:
• A global payment system for “normal” deliveries and C-sections in 2014, working with Blue Cross and a network of obstetrical providers across Rhode Island to make this happen.
• A global payment system for mental illness and behaviorial health care, scheduled to roll out on March 1, 2014

Further, Keefe said that a pilot “conversation” project, undertaken with employees at Care New England, to encourage conversations about end-of-life issues, was being considered for a larger, scalable program.

“The ‘conversation’ project is about training people to have these conversations – physicians, families and patients – before they face abrupt end-of-life decisions,” Keefe said. About 30 percent of Medicare payments occur in the last year of life, and 80 percent of Medicare payments occur in the last month of life, according to Keefe, pointing to the importance both from a cost and care perspective about clarity of wishes for end-of-life care.

The changed relationship between Care New England and Blue Cross – where today they are strategic collaborators, not adversaries – represents an important part of the changed dynamic, according to Keefe. When he served as R.I. Attorney General, Whitehouse recalled, he was the “chaperone” for contract negotiations between the hospital and the insurer, to keep things on track when “voices got loud and tempers flared.”

“Peter [Andruszkiewicz] and I came [to Rhode Island] within two months of each other, and as Peter has often said, we’ve been ‘in violent agreement’ with each other about where health care needs to go in Rhode Island.” The goal, working in collaboration with Blue Cross, Keefe continued, “is to bring the cost curve in line with general inflation for the state over a five-year period.” The nature of our strategic partnership with Blue Cross, Keefe said again, with emphasis, is “to really flatten that cost curve and decrease that cost curve – and maybe even do better than [the rate of] inflation.”

Blue Cross’s chief medical officer sits on Care New England’s strategic quality committee, and Keefe sits on Blue Cross’s strategic planning committee. “That’s transparency. That speaks to the trust and respect and the partnership.”

From chronic care to health care for all
Whitehouse, sounding a bit like Gov. Lincoln D. Chafee, introduced the importance of caring for those adults afflicted with chronic conditions using a tangential story to make his point. In the beer business, Whitehouse began, “they say that 80 percent of the beer is drunk by 20 percent of the people, most of them in college.” In health care, he continued, “80 percent of the cost goes to 20 percent of the patients, most of them patients with multiple, chronic conditions. Giving them better care saves an enormous amount of money.”

One-fifth of all Rhode Islanders – about 200,000 patients – are now being seen by 36 primary care practices that are part of the R.I. Chronic Care Sustainability Initiative, or CSI-RI, according to Hurwitz, the initiative’s director. The all-payer initiative, begun as a pilot program in 2006 under the direction of former R.I. Health Insurance Commissioner Christopher F. Koller, now has plans to expand to cover 500,000 Rhode Islanders, Hurwitz told the assembled group.

CSI-RI, Hurwitz continued, was the progenitor and catalyst for the adoption of the team-based patient-centered medical home model by Medicaid, by Blue Cross [which has invested $60 million in patient-centered medical homes] and by Coastal, which had been one of the original five pilot sites in Rhode Island in 2008.

This “community effect,” she continued, has led to a harmonizing of measures, contracts and incentives by practices. “It’s not just certain patients in the practice; it’s [seen as] across the board advantageous,” Hurwitz said. “It’s changed the model for the way physicians [and members of the team] practice [medicine].

Under Rhode Island’s proposed State Health Innovation Plan, 80 percent of Rhode Islanders would be seen by similar patient-centered medical homes.

From patient to customer
Kurose, who praised Rhode Island as “a real incubator for innovation in health care delivery,” framed the issue moving forward as one where health care needed to adopt some fundamental business principles.

“If we would call our patients ‘customers’ instead of calling them patients, it would be a good thing,” Kurose said. “If you walked into a clothing store to buy a suit, they’re not going to tell you to go sit with the other people and then you’ll get help – they would help you in like 30 seconds,” he said, as the group erupted with laughter. “Maybe we should do that, if that what it means to be a customer.”

Kurose, who is earning an MBA at Yale University, said that the change over to the team-based patient-centered medical home approach has brought “a richer experience of care” to the patients that they can all recognize.

The next step, he continued, is to develop the tools to look at cost efficiency and the health of populations. “It’s a beautiful thing; the better care you take of your patients, the more efficient and cost effective health care becomes.”

Toward that end, Kurose has developed population health management data analysis software and modeling that enables a Coastal multi-disciplinary team to look at which patients are projected to be the most expensive patients in the coming year, looking at claims data, and to make the appropriate interventions.

Data, data, who’s got the data?
Whitehouse introduced the R.I. Quality Institute’s Adams with the hyperbole that Rhode Island had the most “robust” health information exchange in the nation. Adams, in turn, began by noting that it gave her pleasure to know that as she looked around the table, the participants were “either on my board or part of a collaborative relationship.”

Adams touted CurrentCare, the state’s health information exchange, and it’s progress to date, enabling Rhode Islanders to “say yes” to sharing their health data across different medical platforms. What she didn’t mention was that about only one-third of the Rhode Islanders had signed up to date.

She also talked about the importance of CurrentCare’s hospital alert system, letting physicians and practices know if a patient had been admitted or discharged from a hospital, as well as the participation of medical labs and pharmacies in sharing data through CurrentCare.

What she didn’t talk about was the fact that the digital connections between Coastal and CurrentCare were still being constructed between eClinicalWorks, Coastal’s software provider, and CurrentCare.

Two days after the event, a patient with Coastal received an e-mail from her physician asking her to sign up for CurrentCare. “As your physician, I always want to provide you with the best possible care,” the pitch began. “One of the most important tools I have is access to your most complete, up-to-date health information.”

The Coastal patient, when she called the 888-number provided to get more information, was connected to the R.I. Quality Institute. She was told that no, the interface is not operative right now. Yes, the doctor’s office does get compensated for those patients that sign up. And, there is no “continuity of care document,” or CCD, at the moment.

The bottom line
Hurwitz, talking with Dr. Thomas Bledsoe, a physician who is a leader with the CSI-RI, told ConvergenceRI that they had not done research about whether or not patients understood that they were part of a patient-centered medical home. For Hurwitz, that was not necessarily the best question to ask. Instead, she said, in addition to measuring patient satisfaction and outcomes, the question should be: did the patient know that the quality of care they were receiving had improved and was it better?

That, indeed, is the question.

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