What I'm Listening To
find myself looking for more context to understand the changes happening in healthcare. One policy podcast I listen to regularly is The Weeds . In a recent episode, Weeds healthcare reporter Sarah Kliff interviewed Sylvia Burwell , Secretary of Health and Human Services.
1 in 3 healthcare dollars is paid for by Health and Human Services, making them the largest payer in the United States. This podcast was a fascinating explanation of why HHS is changing and what they hope to accomplish through this transformation. If you are like me, understanding why they are making these changes is important. Hearing Secretary Burwell’s thoughts made me much more confident that our organization is on the right track.
"Hearing Secretary Burwell’s thoughts made me much more confident that our organization is on the right track."
Sylvia Burwell Interview, Transcript (below) begins at minute 04:00-06:10
[Secretary Burwell:] We are trying to shift the entire system to focus on Smarter, Better, Healthier - to get to a place where the consumer is at the center of their care. In order to do that, there are three main things we need to do:
- Change the payment system. Now our system pays fee for service and we believe is what we need to pay is the outcome not the output. Paying for the quality that a provider gives you vs. paying for the tests they run.
- Change the way care is delivered. That means that your care is integrated in a way that the dots are connected. An example would be that your OBGYN is connecting to your primary care provider, if you are a diabetic. That they are connected in a way so that your information passes across providers. That you are seen as a whole person. This means, it means that you are going to get better quality because the pieces are connected, it also saves money because it reduces duplicate testing and diagnostics.
- Using data and information in a better way for the consumer. You can have access to your information about be more engaged in your healthcare. And for providers to be able to share in that data.
Chrissy's two-cents: It was really exciting to think about all the work we've undertaken and to see how it fits so closely to her vision. When you're in the trees, it's hard to see the forest. Big sigh of relief. (Feels like a personal pep talk)
Sylvia Burwell Interview, at minute 06:10-08:24
[Sarah Kliff] With all the experiments going on, what pilot or program is an example of what the future of American healthcare should look like?
[Secretary Burwell:] Can I do two?
The first is the bundled payment, and I’m going to use hip and knee, and which is a mandatory bundle. We are saying that you will have to be paid this way in Medicare for hip and knee replacements.
[Sarah Kliff] What is a bundle?
[Secretary Burwell:] In healthcare, the bundle is the concept that you will be paid for the total episode of care. A total episode is your mom is going in for a hip replacement and a couple of weeks in advance someone will come over to the house and tell her to move her dishes to the counter and remove a rug, and identifies all the things that will need to be different when you mom comes home [after surgery]. From that point through the point of the anesthesiologist, the actual surgery, the physical therapy for the 90 days following is the whole episode. Start to finish, how does your mom’s hip replacement go?
We pay for the hip replacement, not for the anesthesiologist or the surgeon cutting or the physical therapist doing 12 sessions. What we pay is for the episode, all together. This leads to everyone coming together as a team to give your mom the best care. That is a bundled payment. What that cuts across is both the payment #1 strategy and the #2 strategy which is the integration of care. We have seen wide price variation for what people pay for hip replacements across the country and we have also seen wide variation in the issue of quality, in terms of outcomes and results. And they aren’t always related to highest cost - highest quality. This is a very exciting way to move both of these dials.
Chrissy's two-cents: It’s powerful to see how the work that our Ortho team has done is right on track–almost perfect. I’m sure if she came and followed our hip and knee patients through the bundle, she would be really wowed. Dory Trimble, Orthopaedic Project Administrator, did so much to incorporate patient input into the design – it’s nice to know that is important to CMS.
Sylvia Burwell Interview, at minute 08:25-12:30
Providers, payers and the consumer all aligned together with data and information that can help us in a way we haven’t before. That’s why it’s a critical time for change in healthcare.
[Secretary Burwell:] The second example looks at prevention. We have been given important authorities by the ACA to try things which we would never be able to try otherwise. An example I’m very excited about is the YMCA Diabetes project. This let us move money to the YMCA as a Medicare provider, which would never have been possible without these authorities. This program was an investment in Diabetes prevention. Their program was designed for pre-diabetic Medicare patients, with the intervention to try to prevent them from becoming diabetic. On a 15-month period, the average body weight loss was 5% and the average savings per participant was $2,600.
What is very exciting is that this particular program was scored by the actuaries, which is the first time that we have seen a preventative program be valued by our accountants. If we are going to expand and invest in innovation, we have to be able to prove it adds value and quality. This is the first time that we can prove that we can achieve important things in the prevention space.
This was a nation-wide pilot. Why the YMCA was so important was because they were connecting people with the things they need to do, they are trusted places. This allowed us to get to the consumer where they are to meet their needs. This allows us to accelerate their understanding of what they needed to do to meet their goals. A great example is a roundtable I attended at the Cleveland YMCA, there were two sisters who spoke, one saying “Well it’s all about the accountability. I had to come in and we met as a group. When I have to announce how I was doing, I couldn’t not produce every week.” We are working on how to scale this in Medicare.
Chrissy's two-cents: This was the first concrete example I’ve seen that connects prevention and population health with real time savings. Gets the imagination going, doesn’t it? Can’t wait to see what Peter Weir, MD and team are thinking about for our system.
Sylvia Burwell Interview, at minute 21:50-23:55
[Sarah Kliff] Is there a particular quality metric where the ACA has made impact?
[Secretary Burwell:] Although quality is very difficult to measure but there are three areas where we are in a fundamentally different place.
- 500,000 fewer readmissions. A readmission is when a person was in the hospital and they leave the hospital and have to come back to the hospital based on the original problem. What you want is a good outcome. You want to pay for outcomes not outputs. What you want is for patients to leave the hospital and not come back, because they are well. And so we have reduced that.
- 17% reduction in harms in the Medicare population. A harm is something that goes wrong in a hospital which shouldn’t. For example, sometimes there are falls in hospitals. Things will happen, but we thought that we had more that would be expected. We have reduced these through incentives and reforming the way we use payments.
- Pre-existing Conditions. Everyone knows someone with asthma or cancer. The idea that if you change jobs you no longer need to worry that you or someone in your family would have to worry that you won’t be accepted for coverage.
Chrissy's two-cents: Our nurses and doctors have worked so hard to reduce readmissions and hospital harm (falls, infections) but it's hard to count what doesn’t happen. We spend so much time thinking about getting better, so I loved the fact that CMS can count it up and that we are a part of this national improvement (go Patient Safety, Infection Control, Nursing Quality and Patient Flow teams)!
Sylvia Burwell Interview, at minute 25:16-26:23
[Sarah Kliff] Why do you think it is difficult for change to happen in healthcare, unlike other industries?
[Secretary Burwell:] Does healthcare function as a market? If I asked all the listeners to take a pad and write down your deductible your premium and out of pocket copays. You will be more likely to be able to tell me what a gallon of milk costs. The point being that consumers don’t treat healthcare the same way. And similarly if you go interview a hospital and ask them what is the cost of X is to a hospital [they won’t have the answers]. We have not been in a place where there is understanding or transparency. The market often drives change, [and the market] isn’t working in healthcare.
Sylvia Burwell Interview, at minute 27:47-28:32
[Sarah Kliff] Do hospitals actually want to improve the marketplace, giving patients the ability to move from one system to another?
[Secretary Burwell:] Most do because they want to be able to serve their patients well. The kind of transparency you are talking about, I would highlight the University of Utah Medical Center and Dr. Vivian Lee and the leadership shown there. They are at the point where they put out the patient ratings of doctors. You as a consumer or patient rate the doctor and it is put on the website, because they want to compete based on the quality of service they provide. That’s how you are going to get to a market that is working.
Chrissy's two-cents: Such a clear and simple way to present why the healthcare market doesn’t work like other markets. I almost dropped my dog’s leash when I heard her talk about University of Utah.
Chrissy Daniels
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