Group Health to lead state health care reform pilots

By Scott Armstrong

The Washington State Health Care Authority has chosen Group Health Cooperative to lead pilot projects to improve health care quality for Washingtonians. Group Health will lead an effort to bring a variety of health care providers from primary care doctors and physical therapists to surgeons and hospitals into an organized group that is collectively responsible for the health of each patient. This model of integrated care is one that has guided Group Health since its founding in 1947.

Bringing providers together, sharing responsibility for cost and quality, is called an “Accountable Care Organization” (ACO) in new state legislation and federal health care reform. The two Washington state pilots will include at least one integrated health care delivery system and one network of nonintegrated community health care providers.

In the first, we will look at how Group Health as an integrated system can develop news ways – including information technology, new shared approaches to patient care and new payment methods – to create more integration with a network of providers outside of our own 26 Group Health Medical Centers and 1,200 salaried clinicians in our group practice.

In the second, we will work with an interested group of non-integrated providers offering expertise and support to help them develop systems to coordinate care efficiently for the patients they share.

The ACO pilots must be developed by January 2012 without using state funding. Group Health may seek federal funds and solicit grants, donations, and other sources of funding. The Group Health Research Institute (GHRI) and Douglas A. Conrad, University of Washington (UW) professor of Health Services and co-director of UW’s Center for Health Management Research, will help evaluate the pilot projects.

We know that part of the answer in fixing our health system lies in doctors working together to create a system that is accountable for the health of each patient as he or she moves through the continuum of care — prevention, diagnosis, treatment, recovery and prevention again.

Within Group Health we have demonstrated that integrated care can provide distinctly better results. This is an exciting opportunity to extend participation in this more holistic approach to providers and patients across the state.

Published on September 2, 2010 in Accountable Care Organization and Health Care Reform. 1 Comment Tags: , .

The strange new world of interim final rules

By Megan Grover

As the implementation of federal health care reform continues full steam ahead, it is worth taking a quick pause to reflect upon how an “interim final rule” works, and to identify the major players in the implementation of such a large and sweeping piece of federal legislation. 

The Department of Health and Human Services (HHS), lead by Secretary Kathleen Sebelius, has been tasked as the lead federal agency to issue rules as part of the massive implementation of the Patient Protection and Affordable Care Act of 2010 (PPACA).  Together with the Department of Labor (DOL) and the Department of the Treasury, HHS has issued a series of interim final rules (IFRs).  Even though the IFRs are subject to public comments throughout a specified comment period, they still have full force of law as presently written. 

The federal agencies will publicly share the comments received by interested parties during the comment period, and take such comments under consideration prior to issuing a final rule.  The public comment period provides an excellent opportunity for key stakeholders, such as Group Health, to influence and help shape the future of the American health care system throughout the federal rulemaking process.  As a long-standing supporter of federal health care reform, Group Health routinely works collaboratively with other industry stakeholders in response to the IFRs with the goal of promoting a post-reform health care system that will not only increase access to those in need, but also improve the quality of care received. 

In certain circumstances, HHS specifically reaches out to the health care industry prior to issuing any IFRs.  For example, HHS has issued a Request for Information soliciting for guidance on both Medical Loss Ratios and the Premium Review Processes in lieu of issuing IFRs at this time.  In these situations, the National Association of Insurance Commissioners (NAIC) is usually tapped to provide relevant feedback and direction.  The NAIC is a nongovernmental agency made up of state insurance regulators from across the entire nation.  Prior to federal health care reform, the regulation of health plans largely rested upon each state’s insurance regulator, so it is natural for HHS to turn to the NAIC for specific direction and candid technical feedback for reform implementation. 

After final rules are issued by HHS, DOL, and the Treasury, state insurance regulators will continue to hold the lion’s share of the day-to-day health plan regulation.  This is because each plan must file with their specific state insurance regulator’s office prior to offering any health plans within the state.  However, the state insurance regulators will now work hand-in-hand with HHS’ newly formed Office of Consumer Information and Insurance Oversight, directed by Jay Angoff, to ensure all health plans conform to federal health care reform standards.  

For these reasons, Group Health continues to foster positive working relationships with both state insurance regulators and federal agencies tasked with health care reform implementation.  As the rulemaking process for federal health care reform carries on, we will continue to be advocates for increased access and quality of care.

Published on August 19, 2010 in Uncategorized. 1 Comment

Highlights from the Colorado Health Foundation Annual Symposium

By Michael Soman, MD

During the last week of July I traveled to the Colorado Health Foundation’s annual symposium in Keystone, CO. It was an honor to represent Group Health in front of 425 people from the worlds of policy, government, business, and health care who want to make a positive difference. What follows are some highlights from the conference. National thought leaders have a great interest in what Group Health does every day.

The speakers were very high quality—people like former U.S. Surgeon General Dr. Richard Carmona and Dr. Elliot S. Fisher of the Dartmouth Institute for Health Policy and Clinical Practice.

Sessions are archived on the Colorado Health Foundation’s Ustream.tv page, and my fellow speakers and I have posted our presentation slides. The Colorado Health Foundation also blogged about all of the major panels and speeches. They even captured featured speakers “behind the scenes” on You Tube.

It’s not the same as being there, but I hope you can enjoy parts of these great exchanges.

A few conference highlights

A chance to talk up our good work. The people I met had all heard of Group Health and have great respect for us. They want to know how we do it. What policies could promote the kind of care we provide? There are so few examples of integrated systems that actually have aligned incentives, created the vision, and built the infrastructure to create better health—and a better value— for patients.

A panel called “Prevention: A Cure for What Ails Health Care?”  looking at preventive care from different points of view. Policy folks are clear that though the new health reform act will “cover preventive services” it is unclear how that will play out in the real world of health care delivery and reimbursement, especially with a dearth of research about how prevention saves money.

An evening debate— Resolved: ObamaCare gives the federal government too much control over Americans’ health care. It was a rousing exploration, in particular of the “Individual Mandate” which has been the lightning rod for the constitutionality of the act. Even so, constitutionality was not the biggest concern in the room. Effectiveness of the act, and its impact on costs, was.

A preview of a documentary to feature Group Health. Journalist and documentary creator T.R. Reid (Sick Around the World) previewed his yet-unfinished film about areas of the country that have found a way to give better care at lower costs. Producer Lisa Hartman came to Group Health about a month ago to interview people related to this documentary, and Mr. Reid is coming later this month.

 It’s broke — now how do we fix it?  The panel I spoke on started with moderator Dr. Jay Want, President and CEO of Physician Health Partners. He gave a context-setting picture of what’s wrong: mostly that our entire system is designed not to enhance health and wellness, but to produce billable events. He closed with that great quote from Jerry Garcia of the Grateful Dead: “Somebody has to do something, and it’s just incredibly pathetic that it has to be us.”

Each of the four panelists got 20 minutes to speak. The idea was to start with the most high level and theoretical and get down to a system (ours) that has actually done some of these things. In that vein, they asked me to “bat cleanup.”

  • John Rother, Executive Vice President of Policy and Strategy, AARP, talked about the patient/consumer point of view, and how the system just isn’t delivering what patients want and need.   
  • Jason Hwang, MD, Executive Director of Health Care, Innosight Institute, talked about “disruptive innovation” in other industries over the last century and how that is playing out in health care. He is the co-author of the highly acclaimed book The Innovator’s Prescription: A Disruptive Solution for Health Care
  • Harold Miller, Executive Director, Center for Healthcare Quality and Payment Reform, is an expert in payment systems and paying for value instead of volume. He talked about the health care “non-system,” various perverse incentives, and how we might align incentives and policy to actually give better care and lower costs to our patients.

I talked about our Medical Home (that’s what I was asked to do) but also touched on other delivery system reforms. I put our work in the context of our 63-year history, our unique marriage of finance and care, and our founding mission in 1947: to serve the greatest number (and to remove affordability as a barrier to high quality care).

I closed with…

  • We are in a struggle for the soul of American medicine. Don’t underestimate that struggle or your role. The system will implode if we don’t fix it. 
  • We can only do this together by crossing our tribal boundaries, political parties, health plan/delivery system boundaries, and primary care/specialty boundaries. 
  • We need to learn together with open minds, unwavering principles, and unflinching focus. 
  • We can do this.

Then we fielded an hour of Q&A with the 350 or so folks in the audience. They were clearly fascinated by what we have done—and are doing—and how we look at our work. There are so few models that work. Our work at Group Health was so appreciated.

Published on August 13, 2010 in Health Care Reform. 2 Comments Tags: , .

Addressing problems coverage alone can’t fix

By Eric Larson, MD, MPH
You’ve got to feel for Richard Kronick, professor of family and preventive medicine at the University of California San Diego. His Health Affairs “ 2009 article of the year” uncovered unexpected news about the relationship between U.S. health coverage and mortality.
“It was not the answer I wanted,” the former Clinton administration health policy advisor told Politifact.com at the height of last summer’s health reform debate. He added that he might lose a few friends over the work. Even so, he was appointed Health and Human Services deputy secretary of health policy in January 2010.
Dr. Kronick’s findings contradict a 2002 Institute of Medicine (IOM) estimate that uninsurance leads to 18,000 excess deaths annually. Published online last April, his paper concluded that extending insurance coverage to all adults would do little to reduce U.S. deaths.
The work was lauded for wisely adjusting data for demographic and health factors, a step the IOM panel didn’t take. Dr. Kronick showed no difference in the risk of subsequent mortality for uninsured respondents than for those covered by employer-sponsored group insurance.
In other words, while health insurance is necessary, just providing coverage to more Americans alone offers no magic fixes. A sedentary smoker with diabetes is equally likely to die prematurely if insured as uninsured. Simply carrying an active insurance card will not control your blood sugar, help you stop smoking, or motivate you to get moving.
What can make a difference, however, is getting care that actually prevents illness, effectively treats acute injuries and illnesses, and improves chronic conditions. As health reform takes hold, we need much better evidence about the elements of such care and how to deliver it efficiently and effectively to an influx of previously uninsured patients. “Rescue care” at hospital emergency departments may have kept the uninsured alive, but they are living with a higher burden of chronic illness. And rescue care is costly and not very effective anyway. To make good care accessible and affordable for all, we must eliminate waste and invest resources in care that truly improves health.
The National Institutes of Health ( NIH), through its Director Francis Collins, intends to address these kinds of issues in its newly conceived HMO Collaboratory. This will be a national population laboratory comprising 15 U.S. health plans of the HMO Research Network ( HMORN), including Group Health. The HMORN includes more than 350 multidisciplinary scientists studying 13 million covered individuals.
Dr. Collins approached the HMORN leadership early this year to explore forming the HMO Collaboratory because he wants the nation’s research infrastructure to speed up comparative effectiveness research ( CER)—which is best conducted in large, real-world patient-care settings like the HMORN health plans. The Collaboratory can leverage the Network’s “learning health care systems”—where research and practice influence each other.
Dr. Collins values the HMORN’s 16-year history of successful collaboration in multi-site, NIH-funded research on cancer control, cardiovascular health, immunization, drug safety, and so on. His idea is to infuse the HMORN with new resources so it can address more topics, expand its data capabilities, and involve new partners and scientists in its research. This is breaking new ground not only for the HMORN but also for NIH, which traditionally contributes knowledge but aspires to do more improvement.
NIH informed Group Health Research Institute (GHRI) in late June that the HMORN could apply for a one-year $1 million administrative supplement to plan for and establish the Collaboratory. This supplement was assembled in three weeks’ time and submitted on July 31. GHRI will take the lead in the Collaboratory; I will serve as principal investigator, Sarah Greene as managing director, and Ella Thompson as project manager. We will also plan to name a business manager and an administrative coordinator for the project. We are proposing a Collaboratory Council comprising the GHRI team plus four to six investigators from various HMORN sites. We will also identify co-leads for the major scientific areas of the Collaboratory (large-scale epidemiology, health care delivery research, and clinical trials).
The HMO Collaboratory is an ambitious undertaking for GHRI and our HMORN partners. But other network leaders and I agree this extraordinary opportunity comes at an unprecedented time in the evolution of the nation’s health care system. We are committed to putting our best effort forward.
Published on August 10, 2010 in Access to care and Health Care Reform. 1 Comment Tags: , .

Meaningful Use

By Matt Handley, MD, Associate Medical Director, Quality and Informatics

The 2009 economic stimulus package included grants and incentives to encourage medical practices to invest in electronic medical records. The legislations required that electronic medical records meet a standard of “meaningful use.” They must be more than converting paper records to digital records. They must improve the quality of care, such as:

  • Improve care coordination
  • Reduce healthcare disparities
  • Engage patients and their families
  • Improve population and public health
  • Ensure adequate privacy and security

The specific standards of meaningful use were defined in June. Continue reading ‘Meaningful Use’

Published on August 6, 2010 in Health Care Reform. 0 Comments

What’s quality got to do with it?

By Diana Birkett

Medicare Advantage Quality Bonus Payments and the CMS Star Rating System

The federal health reform bill passed in March took a major step forward ‘on the path toward paying for health care not solely based on the cost of delivering care and the volume of services delivered, but by the quality of care provided to patients.  A significant part of this change will take place in the Medicare Advantage (MA) program, where under a new payment system, about 5% of MA plan payments by 2014 will depend on the quality of care and service delivered to people enrolled in that plan – and up to 10% in certain counties.  The new payment system not only drives toward more efficient spending in Medicare, but also toward greater emphasis on quality of care and service.

With this change, quality of care and service is becoming more important than ever, with actual economic consequences attached.  But “quality” can seem a nebulous term; the definition of quality for MA will be increasingly important.  CMS is in charge of setting this definition, building off of the “Star Rating” system they have used for the past several years, publishing plan ratings on the Medicare.gov website so that prospective plan enrollees can comparison shop.  CMS has been hearing from patient advocates, quality experts, Medicare plans, and other stakeholders to help improve the criteria for the Star Ratings, and anticipates releasing the specifics on an improved system sometime later this summer.

Group Health offers coverage to nearly 60,000 Medicare beneficiaries through the Medicare Advantage program.  We have always taken seriously both the quality of care and the quality of the service we provide to our patients.  As a result, we’re proud to be rated highly for our quality of care under CMS’s existing system and ranked “Highest in Member Satisfaction among Commercial Health Plans in the Northwest” for our quality service by J.D. Power and Associates.

We believe all plans and providers should be held accountable for patients getting good care.  As CMS works to further improve their definition of quality, we encourage them to use evidence-based measures, to emphasize the quality of clinical care (actual patient-provider interactions), to recognize both individual patient and population health, and to focus on measures of quality that will drive improvement in Medicare over a period of time.

Please comment to let us know what quality measurements are important to you.

Published on August 4, 2010 in Health Care Reform and Medicare. 0 Comments Tags: , , , .

Measuring Up

By Michael Soman, MD

Quality. Ask a hundred people to define it, and you’ll get a hundred answers. In the last decade we’ve collected more performance data and industry rankings than ever to sharpen that fuzzy definition. Members, health coalitions, purchasers, consumer advocates and the media all rate Group Health’s quality in different ways.

Continue reading ‘Measuring Up’

Published on July 30, 2010 in Health Care Reform and Quality Health Care. 0 Comments Tags: , , .

The State’s Big Role in Reform

By Scott Plack

Federal health reform will produce major changes, with coverage mandates bringing more than half a million new people in Washington state into the health care system starting in 2014. Much of the focus of the federal reform bill is on getting people covered – a critical and historic step – but we must also think about how these people will access health care, and how to ensure they get high-quality, affordable care.

While the health reform bill precipitates sweeping changes and greater federal role, it does not sufficiently address how to provide effective, high-quality care to patients while keeping costs down. Here is where the state can and must have a significant role.

Continue reading ‘The State’s Big Role in Reform’

Published on July 27, 2010 in Access to care and Health Care Reform. 1 Comment Tags: .

Everyone Gets Preventive Care — Finally

By Megan Grover

Group Health has always been a strong proponent of preventive care and evidence-based medicine, so we were very pleased to see preventive services stand out as an important aspect to federal health care reform for health plans.

When the U.S. Departments of Health and Human Services, Labor, and Treasury released the highly anticipated interim final rule (IFR) for preventive services last week, it moved the health care system in the right direction by helping Americans receive the preventive health care they need and thereby helping to prevent more costly and painful illness and disease down the road. The regulation, which as an interim final rule has the full force of law despite being open to comment by stakeholders and the public, requires health plans to cover in-network preventive services with zero out of pocket cost for the patient. Health plans may still require enrollees to share a portion of the cost for preventive services delivered by out-of-network providers.

Continue reading ‘Everyone Gets Preventive Care — Finally’

Published on July 22, 2010 in Health Care Reform and Preventive Care. 0 Comments Tags: .

The risk and opportunity of ACOs

By Michael Soman, MD

You’re a patient getting care from a Group Health physician in a Group Health facility. All of the conditions are right for an evidence-based, medically appropriate, smooth and integrated experience. Our care model, our people, our technologies and incentives make it possible.

But here’s the reality: we don’t own all of the buildings where our members receive care. We rely on thousands of contracted medical providers in dozens of non-Group Health facilities. Two-thirds of our clinical costs are incurred outside our own walls and in many cases care is provided by non-Group Health staff. And I believe in the future we’re going to have to look outside our own walls even more.

Continue reading ‘The risk and opportunity of ACOs’

Published on July 15, 2010 in Accountable Care Organization and Health Care Reform. 0 Comments Tags: , , .