Earlier this fall, we heard Jack Rowe describe his own leadership journey at Aetna, which The Washington Post just featured in a piece called, “Case In Point: To go from worst to first, alter the business model.”  Dr. Rowe is currently a Professor in the Department of Health Policy and Management and Chairman of the Board for the Mailman School of Public Health.

The article cited his successes at the helm of Aetna between 2000 and 2006. When he joined the company it was mired in class-action lawsuits and losing $1 million a day. Dr. Rowe’s approach was to re-focus Aetna on quality in order to better serve its members, improve relationships with physicians, and build a new portfolio of public interest programs.  He took the industry’s Orwellian “medical loss ratio” concept and turned it into a measure of health care value that Aetna delivered to its subscribers.  By redefining Aetna’s purpose around health care quality, he effectively transformed and reinvigorated its business.

The article reminded me of Dr. Rowe’s admonition to us to “Lead – not manage.”  These are  different things.  A leader must create, sustain, embody, and invoke the mission, vision, and values across the organization – be it large or small – at every opportunity.  I think this takes courage.  You have to stand for something.  You have to connect with a deeper purpose in yourself and you can’t be afraid to try and inspire it in others.

U.S. health care cries out for transformational leaders.  If ever there was a time to cultivate the transformational leader in yourself – it is now.

What does all this have to do with the EMPH program?  Well, recently, EMPH Alum (’92) Adewale Troutman, MD, MPH and former dean of South Florida’s College of Public Health was elected President of APHA.  Dr. Troutman trained as a family physician and has held positions in clinical emergency medicine and hospital administration.  In a Q&A (which you can read here) Dr. Troutman notes that his passion for public health is driven by his desire to address the issues of health equity and human rights – “making the world a more equitable place.”  The notion of public health as a great equalizer (i.e., clean water for all, access to care for all, eradication of diseases for all, addressing root causes of poor health for all) is inextricably linked to the promotion of social justice.

Dr. Troutman’s leadership and commitment to these ideals was evident in his interview.   He believes we have a “system-wide, unethical and unjust health care system” and hopes that new students will be more fired up about human rights and social justice.  In his new role, he plans to prioritize APHA’s advocacy efforts so that it can lead policy change more effectively.  Cultivating international partnerships with organizations such as WHO (with whom he has worked with in his own career) as well as other coalitions are also top on his list.

Dr. Troutman recalled his time at Mailman positively, noting that the Exec program enabled him to achieve his MPH in a way that no other program could.  And he left us with some words of advice:  “Stay focused, think big and think globally.  Think in terms of collaboration, community activism, advocacy, and never, ever give up.”

A couple of additional APHA things -

• You might want to join the APHA Group on Linked In (or check it out)
• Also, APHA (in partnership with United Health Foundation) recently released its annual “America’s Health Rankings“.  New Jersey is #11; New York is #18; Ohio is #36; California is #24 (up from #26-woohoo!); Pennsylvania is #26; Florida is #33; and . . . drumroll please:  Connecticut is #3.  There’s additional data in the report on obesity as well.

They are calling my flight; please forgive any typos or grammatical errors in this post.  (Is this a blog or a letter, who knows).  I look forward to seeing all you EMPHers tomorrow!

As we’ve blogged in the past, oral health is integral to overall health and should therefore play an important role within the PCMH. Access to preventive dental care can also advance the twin goals of higher quality primary care and lower health care costs overall. In 2009, the California Health Care Foundation reported that 80,000 emergency department visits a year in that state alone for preventable dental conditions.  Surprisingly, statewide, the ED visit rate (without hospitalization) for preventable dental conditions ran higher than that for diabetes.

Which is why the accomplishments of two EMPH alums (’04) in the area of oral health are so important. In their recent Oral Health newsletter, the American Academy of Pedicatrics honored Dr. David Krol as an Oral Health Champion, celebrating his work to develop partnerships between pediatricians and dentists. Dr. Krol (a pediatrician himself) has been active on a committee affiliated with the Institute of Medicine regarding access to oral health services. He has also contributed his expertise to the oral health efforts of the American Academy of Pediatrics in addition to serving on review panels with the US Health Resources and Services Administration and the National Institute of Dental and Craniofacial Research. Dr. Krol was recently involved in winning a DentaQuest Foundation grant on behalf of the New Jersey Chapter of the American Academy of Pediatrics. In all, the foundation awarded funding to 20 state organizations that support community partnerships as part of its Oral Health 2014 Initiative to Eliminate Oral Health Disparities.

Kevin Earle, a former classmate of Dr. Krol, was also instrumental in securing a DentaQuest grant. Mr. Earle is the Executive Director of the Arizona Dental Association and has an extensive background in regulatory management. He recently acted as an author and major force behind the DentaQuest grant for Arizona. The funding will provide resources to confront critical oral health deficiencies among the 21 Native American Tribes in Arizona, where children have decay rates that are 400% greater than the national average and one in four tribal elders is without natural teeth. The grant will help support strategic collaboration between the Native American community and both public and private stakeholders.

Kudos to our EMPH oral health champions!

But implementing an EHR system is no easy task.  It’s expensive.  And it tends to disrupt the work flows that follow paper charts, requiring new ways of delivering care, interacting with patients, and managing business processes that can be daunting to providers, front office staff, billers, and managers alike.

This makes me think of a quote that Senator Ted Kennedy’s widow shared at a conference I attended last year.  She said it was a favorite of his.  That is, “for every difficult, complicated  problem there is always a simple and easy solution.  And it’s WRONG.”  EHRs are a little like that.  They offer a complicated – yet essential – solution to help achieve the challenging goals of higher quality and lower costs.

The class of 2012 is fortunate to have a HIT-whiz among us:  Rami Rafeh.  Below are some HIT questions I posed to Rami, along with his responses.

Tell us a little bit about how the Obama administration is attempting to incentivize the adoption of electronic medical records across the country.  What progress has been made?

Under the Health Information Technology Act (or HITECH, enacted as part of the 2009 federal stimulus bill), a physician can get upwards of $44,000 in incentives to update their practice with an electronic medical records system.  They must also report on certain quality and other metrics moving forward, to show that they are using their electronic systems in “meaningful” ways that are improving patient care and outcomes. (The ONC says that 41% of private physician practices are planning to achieve meaningful use of EHR, and a third of them will do so this year.)  Another component of HITECH will establish regional information exchanges (RHIOs) and other network enhancing interfaces.  There is also an education component which provides training for 50,000 health information employees to prepare for the new demands of this exciting field.  Columbia saw its first cohort graduate last semester with many students receiving subsidized tuition by the federal Office of the National Coordinator at Health and Human Services.

One of the big problems with the way electronic health records is unfolding is the fact that all these programs can’t talk to each other. So my pcp can’t get feeds from the ED which can’t get data from the lab etc, etc. Aren’t we simply building more electronic silos and where does this eventually get us?

The real foundation of what the Health IT movement is all about is interoperability.  The way I look at upgrading an existing network is like changing the wheel of a car while it’s in motion.  We have found that even in the same organization, you can have upwards of 1200 interfaces (components that try to make different systems ‘talk’).  Our current network is so complex and the information is just too sensitive to simply start over.  This is why some capital budget projects are +40% Health IT.  HL7 is a language that creates a standard for health systems to communicate with one another, but so much work is already out there with hundreds of different vendors, it is pretty much like installing Windows on a Mac.  The hope is that as we are training our professionals better, they understand the existing problems and can set up a framework that promotes interoperability and at the same time become silo-busters.

It also seems like there´s a tendency to view health information technology as the solution to health care problems (inefficiency, poor quality, etc).  But aren´t these problems really caused by – and solved by – people?

Absolutely.  I think at times we tend to over-exaggerate the outcomes that Health IT offers.  As we always say in industry: garbage in, garbage out.  We have not gotten to the point yet where computers can intelligently clean up our data.  Health IT does offer a way to identify work stream inefficiencies, reduce redundancies when properly executed, and set up a framework for sharing health information across multiple computers whether within the same service line or across different organizations.

Tell us a little about the program you just completed (in conjunction with your full time job and EMPH, I might add)?

The program is six-months in duration and provides students with the practical knowledge and skills required to use electronic health records (EHRs) in health organizations. The program aims to train each individual for one of three roles defined by the Office of the National Coordinator (ONC): 1) Privacy and Security Specialist, 2) Programmer/Software Engineer, and 3) Health Information Management and Exchange Specialist (where I focused).  It was very exciting, and I liked it so much that I am assisting teaching this semester selfishly so that I can stay close to the material.

Why are you so passionate about HIT?  What´s your dream job?

I never really understood why, as a kid, I was so completely engaged in computers the way I was.  My mother told me that I was born with a mouse in my hand, so it was only fitting that I continue down that path.  I think the thing that excites me about Health IT is that it requires such strong leadership, a strategic mindset, and a lot of creativity if you can believe it or not.  What we don’t need right now is more of the same, but rather more of what I like to refer to as change champions.  My ideal job would be to work with a dream team like Farzad Mostashari from ONC, Todd Park from HHS, and other visionaries that just will not settle for status quo.

If you were to recommend one article or report or website about HIT that we should absolutely read, what would it be?

I would love to give you an article that ‘sums’ everything up, unfortunately there is so much conflicting data out there that even to this day, I’m still learning.  What I did find helpful was a book that gives you a very good foundation in what is going on in this country regarding the health IT movement, and coincidentally was written by an EMPH alum, Ken Ong: Medical Informatics: An Executive Primer, Second Edition.

"From the Desk of Bob Mankoff"

Meanwhile, Steven Pinker, the Harvard psychologist, has a new book out called The Better Angels of our Nature: Why Violence Has Declined,” which argues that human kind has seen a steady decline in violence since the dawn of time and that we’re living in one of the safest, most peaceful eras in the history of the world.  Elizabeth Kolbert has an interesting review of Pinker’s book in The New Yorker, where she points to some gaps in his logic (er, the First World War and the Second World War).

Pinker’s hypothesis is interesting when you consider the public health side of things.  The CDC reports that violence is one of the top 10 causes of death in the U.S. for people age 1 to 64. Moreover, decline or no decline, violence as a cause of death disproportionately effects young, low-income men of color. The CDC’s  Mortality and Morbidity Weekly Report dated January 14, 2011, discussed homicide as a cause of death as follows:

Similar to previous findings, results of this study indicate that homicide disparities by age, race/ethnicity, and sex are evident, and the homicide rate is particularly high among young black males.  Individual factors (e.g., employment status, and socioeconomic factors (e.g., poverty and economic inequality) play critical roles in racial/ethnic disparities in homicide. For example, persons of a minority race are more likely than those of other racial/ethnic backgrounds to be unemployed and to live in economically impoverished residential areas; both factors are associated with a higher homicide risk.

Which means that if we’re going to address the public health issue of violence, we have to address the causal factors of unemployment, poverty, and economic inequality.

If you’d like to see additional amusing New Yorker cartoons on the Steven Pinker theme, see Bob Mankoff’s blog.  And if you take the murderous approach to management, let us know how it goes.

All too often, people think of dental care as a medical luxury.  And yet it is an essential component of overall health.  Dental disease is linked to heart disease, stroke, diabetes, and more.  Maternal periodontal disease has been linked to pre-term births.  According to the National Children’s Oral Health Foundation, pediatric dental disease is 5 times more common than asthma and 7 times more common than hay fever.  Among low-income adults, unchecked dental disease is a fundamental barrier to getting out of poverty because rotten and missing teeth prevent individuals from obtaining a job.

A recent article in The Atlantic showed (not surprisingly) that the rate of dental visits across the U.S. closely tracks socioeconomic status.  People who possess college degrees and work in professional fields see the dentist more often.  People who live in states with the lowest uninsured rates see the dentist more often.  People who live in Massachusetts and Connecticut are more likely to have seen a dentist in the past year than those who live in the South.

Keri Discepelo, D.D.S. and Andrew Kaplan D.M.D. (class of 2012) cite new opportunities to increase access to dental care and reduce disparities in their article, The Patient Protection and Affordable Care Act:  Effects on Dental Care.  Keri and Andrew note the access issues faced by some 40% of Americans who don’t have dental insurance, a dental safety net that’s stretched thin, and the fact that the majority of private and group practice dentists are not Medicaid providers (since the reimbursements are low and don’t cover costs).  With the current economic crisis, more states are eliminating the dental benefit from their Medicaid programs entirely, at least for adults (see: California).

Keri and Andrew helpfully summarize PPACA’s major oral health provisions which particularly benefit children and also increase prevention education across the country.  They also outline different strategies to improve dental health access and outcomes.  These include using  dental “auxiliary” staff like hygienists, dental assistants and community health workers to provide prevention education.  More controversial is the development of mid-level practitioners to provide a basic level of dental care which could particularly help rural or underserved areas facing dentist shortages.  Interestingly, their article also outlines the differences of opinion about PPACA among different facets of the dental profession (there was resounding opposition to the mid-level provider idea and the ADA opposed the bill because it didn’t address Medicaid reimbursement issues and because it didn’t define a basic adult dental benefit for coverage).

One young mother came to our clinic after she’d lost her front teeth in a car accident.  She didn’t have insurance, but thanks to donations we were able to provide her with new front teeth.  We took two photographs of her – before her new dentures, and after – and mounted them side by side.  On the left you saw the hopeless gaping smile of a disadvantaged person.  On the right you saw a gorgeous, confident, professional-looking brunette with big brown eyes and a warm smile.  Two different people facing two different futures.

Here we are, half-way up MPH mountain with 12 full months behind us, and a mere, piddling, inconsequential 12 more to go.  But seriously, the view is great.  Really, really great.  We are all in pretty good shape (except for Melanie, who broke her ankle but in actual fact she did this at home, on her own time, and not on MPH mountain).   At any rate, we’re all still standing (except for Melanie, of course).  Did I mention that during our slog we have given birth to three whole babies (with two more on the way)?  And that one of us has gotten betrothed?  And maybe 5 or  6 of us have taken on new, more challenging jobs?  While taking biostats?  Yes, we have been extremely, awesomely productive.

Now that we have wowed you, we thought we’d offer up some (hopefully) helpful tips as you set out on your own climb.    To wit:

1. Just wondering: do you know the Serenity Prayer?
2. Okay, the program is truly what YOU make of it, so just do the work – to the standard of your own internal barometer.  Don’t expect others to set the bar for how much you will get out of the program.
3. Don’t hesitate to network within the Mailman community – with classmates, professors, and even faculty you don’t take a class with.  The Mailman family is very welcoming – become a part of it.
4. Re time management:  1) focus on it and 2) forget about it, you’re already overbooked.
5. Grades do not matter!  You are here for something way more significant and meaningful than grades!
6. Likewise, don’t stress about who will be the class reps, or if you will ever love your iPad (you will), or if you don’t love the food, or if you prefer Rosenfield over Russ Berry - in short, don’t sweat the small stuff.  Remember why you’re here.
7. However, if you do happen to get an A, resist the urge to lord it over your teenager.
8. Ask for help – turn to your classmates with abandon.  They are the ones who truly understand what you’re going through.
9. Raise your hand , speak up, ask questions, be provocative.  Your honest point of view  – no matter what it is – will enrich the classroom experience for everyone.
10. Be open to the differences in your classmates.  Don’t write anyone off because you don’t see eye to eye, or you discern fundamental differences in your outlooks, goals, or motivations.  If we’re really going to make the health care system work better, we need to work better together.
11. And  finally, from the inimitable Jason, please remember that, “whenever the complexity of the US healthcare system becomes too much, just take a step back and say to yourself: ‘by refusing all medical care, Christian Scientists in the US live almost as long as the average American.’”

We’ve already noticed (and commented to each other – oh yes, we talk about you) that you are an extremely warm and friendly group. Please don’t hesitate to ask for our help or our thoughts on anything that comes up.  We wish you a successful, rewarding and fun journey!

Sincerely,

Class of 2012

Did you know that Medicare only pays an ambulance when they drop off a patient at an emergency room?  That’s right, no payment for a highly sophisticated dispatch system that must be on on alert at all times; no payment for evaluating a patient in their home or at a scene; no payment for providing life saving or other treatments to a patient on scene.  Furthermore, the EMS agency requires that its providers never tell a patient they don’t need to go to a hospital (even if the patient asks)!  Patients must sign a “Refusal of Medical Aid” statement and occasionally must speak with an online medical control physician before being released from the care of EMS.  If an agency believes that it might not be in the best interest of a patient to go to a hospital, or if an alternative destination such as a primary care office, dialysis center, urgent care center, or public health clinic would be more appropriate, they must choose between the patient’s best interest and their own financial interest.

This kind of perverse financial incentive is rampant throughout our healthcare system.  However, while federal and state efforts at health reform are finally seeking to realign incentives in the rest of healthcare, prehospital care has been left out. Ironically, this is despite a long history of EMS providers trying to change their payment model from the current fee for service system to one that better represents their role as a public good.

The key to understanding the advantages of EMS payment reform is the idea of staving off “downstream costs.”  If an EMS agency is perversely incented to bring a patient to an ER (for whom there is little marginal benefit for being there) in order to collect a $450-750 EMS bill, they have now triggered an ER charge in excess of $1000 simply by having the patient register at the hospital.  This is a swing from $0 for all the care provided by EMS minus the transport to approximately $1500 simply because they transported the patient to the ER.

Alternative payment models might include global payments, block grants, shared savings agreements or even simply a division of fee for service payments to reward all the other useful components of EMS besides the drive to the hospital.  Once you change the payment model, a variety of alternative models of EMS become financially viable.  Systems in which prehospital care agencies transport patients to the most appropriate destination, or not at all, start to make sense.

Can we trust EMS to make these decisions?  Well, EMS agencies already are overseen by physician medical directors and have QA procedures in place.  Certainly, more investment in medical oversight is required but consider the rapidly advancing state of telemedicine / telehealth products.  What might not have been possible without extraordinary investments are now available through personal mobile devices.  Thus, I propose that small investments in prehospital care systems could be offset by dramatic savings in unnecessary ER visits all enabled through a change in the way we reimburse EMS.

A world of possibilities begins to open up.  What if a prehospital care system could refer non-acute patients for followup? What if EMS providers could make referrals for social work, case management, health navigators? What if they could coordinate with a patient’s primary doctor, or with the specialist who has been caring for this patient’s condition that led to the call?  What if they could provide biometric data, basic physical exam findings such as lung auscultation and use a videophone to allow a doctor remotely to have eyes on the patient.  Could some or all of this obviate the need for transport to an emergency room?  Could it do so at lower total cost to the system?  Could this lower a patient’s cost?  Could this avoid missed work days, lost productivity and other costs to the rest of the economy?

Can we go even further?  Can EMS agencies, with their existing skillset function outside of the emergency context?  Can they visit patients in advance of their calling 9-1-1?  Can they work on preventing emergencies rather than just treating them?  I believe that the answer to all of these questions is a resounding yes!  These ideas are encapsulated in a term “community paramedicine.”

Under new experimental payment models such as accountable care organizations, wouldn’t it make sense for EMS to be better integrated into the health care system?  If care management and medical homes are good ideas because they can avoid ER visits, it seems contradictory to not allow EMS to intervene at the point of contact to avoid unnecessary ER visits.  If health systems are training legions of allied health professionals to take their skills into the community and into patient’s homes as part of better quality and patient centered-ness, it seems contradictory to not use a class of health professionals already trained to work in the out-of-hospital environment.  My hope is to realize a new vision for healthcare, one that harnesses the full potential of prehospital care systems in order to achieve better quality and lower costs.

– Kevin Munjal MD

The result?  Payers doled out higher fees to US primary care physicians for office visits and much higher fees to orthopedic physicians for hip replacements than payers in the comparison countries.  US primary care and orthopedic physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts.

Remember Michael Sparer’s final lecture?  A litany of price comparisons between the US and other countries (for MRIs, CAT scans, coronary bypass surgeries, salaries, etc) revealed that US consumers pay more than just about everyone for a variety of health services.

Meanwhile, CMS is already working to reduce Medicare payments  to hospitals for 30-day readmissions, and the prospect of reduced Medicare reimbursement for physicians is also looking more likely.   That said, who is willing to accept lower prices in order to contain the rate of health care cost growth in the US (and prevent the ship from sinking)?  Please step forward.

]]> http://columbiaemph.wordpress.com/2011/09/25/1148/feed/ 0 lesliec123 http://columbiaemph.wordpress.com/2011/09/20/michael-sparer-prescient/ http://columbiaemph.wordpress.com/2011/09/20/michael-sparer-prescient/#comments Wed, 21 Sep 2011 03:04:25 +0000 lesliec123 http://columbiaemph.wordpress.com/?p=1144 Continue reading →]]> How nice to read about the prescience of our own beloved Michael Sparer in a recent blogpost by the Incidental Economist (who is wonderfully fundamental imho).

The post references a 2003 Health Affairs article by Dr. Sparer and Lawrence Brown conveying a message we heard loud and clear in our health policy class: that is, that health care reform will likely be advanced by incremental increases to the means-tested Medicaid program as opposed to the launch of a universal coverage program in one fell swoop.  As we all know, the former is essentially what the Affordable Care Act accomplishes.  A public option?  How quaint!  Sadly (unbelievably) America’s model universal program, Medicare, appears to be in the political cross hairs with proposals to extend the eligiblity age under serious consideration.  Sigh.

Here’s the Incidentalist:

Brown and Sparer were right.  Insofar as public insurance is concerned, expansion has looked a lot more like Medicaid incrementalism than Medicare universalism.

Are you an incrementalist or a universalist?  (Do you have a choice?)  At any rate, it’s nice to see our professor’s name in lights.  Check out the post.