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Sunday, February 28, 2016

Improving the Healthcare System Is an Endurance Race: Are you Part of the Team?





As the Democrat and Republican Presidential primaries heat up, the topic of healthcare is front and center…and for good reason. The United States health care system is the most expensive system in the world but consistently under performs about other countries on most dimensions of performance. With the US economy in turmoil, all the candidates agree on one fact; allowing trillions of dollars to continue to be spent on a system that provides a poor return on its investment does not make sense. Where they all differ is how to fix the system.   

It is not a surprise that our political leaders don't agree. Heath care is personal and is individual to each person. That is why the only way to improve the healthcare system so that it provides safe, quality, equitable care for every citizen of the US is for each of us to do our part. 

I put together this post to share where our healthcare system is today and the important work that is ahead of us. Take time to read this post and share your thoughts and comments. I am not asking for political comments, but common sense thoughts you have regarding how you are doing your part in improving our healthcare system, so it works for each of us when we need it. 

A Starting Point

As we all know, President Obama and the US Congress were able to pass the Affordable Care Act in 2010.  The law is not perfect and can use tweaks in many areas, but it was a starting point to address some of the gaping holes in our health care system that were driving up costs year after year.

The law focused on three critical elements that are fundamental to ensure a sustainable healthcare system that can meet the needs of its citizens. The fundamentals are cost, quality, and access. The architects of the ACA have put into place strategies that mandate that every citizen is to have health insurance. Having healthcare insurance allows consumers to receive preventative care to detect problems early and receive treatment when an issue is found. Also, having adequate coverage is needed if an unexpected injury or illness occurs. As I learned last year when I was diagnosed with a brain tumor having health insurance through my employer allowed me to have access to an expert treatment team that diagnosed and treated me.  If I did not have health insurance, I would be experiencing enormous debt due to astronomical medical bills and loss of income due to my inability to work. In addition, I probably would not have seen the excellent team of doctors who saved my life.  Everyone in the US should have access to affordable healthcare insurance as a citizen of this country. The ACA gave those who do not have access to health insurance through their employer a way to purchase it.

Other strategies that are being put in place are focused on how to change how healthcare is paid for as a way to control escalating costs. Traditionally, healthcare has been paid for by insurance companies based on what a physician ordered. No questions were asked as to the need, benefit, evidence and expected outcomes of tests and or procedures. A doctor simply wrote an order; the test was done and a bill was generated.  That is how the system was set up to work. Today, payers require a reason before a test or procedure is done. They need evidence to support the order. Today there are scientific guidelines that are used to guide treatment. Using evidence to support decisions has helped to eliminate many of the tests and procedures that were done simply because they were available.  Yes, this process has put an additional burden on the physicians to explain their rationale for their decisions.  Most doctors have adapted to this process and supply the information needed, gain approval and move forward. Studies also show that as a result of these rules, over-utilization is down which has had a dramatic impact on overall healthcare spending.

Another strategy that is being put into place is that physicians and other providers are being held accountable for their outcomes. The strategy is set up to pay providers who achieve positive results extra dollars over the fixed payments that are part of their contracts with payers. This concept has resonated with many physicians who have always gone the extra mile for their patients but were not paid any more than those who did not go that extra mile. Doctors love competition, so this strategy is allowing physicians and other providers to vie for extra payments for taking the time to educate a patient to improve their health, for overseeing care coordination and for working with the family to decide on a course of care for an elderly patient.  

The theory behind each of these strategies is that if the care provided is evidenced based, safe and specific for the patient, costs will be lower, and the patient experience will be improved.  Statistics show that despite the negative rhetoric about the Affordable Care Act, the strategies are working. Again, it is not perfect, but it is a start.

Changing the American healthcare system is a massive endeavor and will take time as the infrastructure of the system has to be retooled. As a result of the ACA, changes to the healthcare infrastructure is being put into place. Such things as health information technology are becoming more widespread and helping physicians, hospitals and other organizations to collect data that provides the information they need to know how they are doing from an operational, quality and financial standpoint. Before the law, the system had no way to measure data. Today, executives have the information they can use to make informed decisions on the workings of their organizations and the outcomes produced. They can see information on quality issues and where they are doing well or where they need to improve.

In addition to data, technology is allowing information to be shared among providers and organizations. Sharing of information about patients who transition through the system has reduced errors and duplication. As a result, hundreds of thousands of dollars has been saved, care has improved for patients as the providers have the information they need in real time when they are part of a connected healthcare system. There is still work to do so that the entire healthcare system is interoperable, and all systems can talk to each other in a secure environment. Until this occurs, we will still have gaps, but it is a start.

Another strategy taking place is for physicians, nurses, pharmacists and other members of the healthcare team work together as a team. The average person reading this post may be surprised to learn that most physicians and other members of the healthcare team do NOT work collaboratively. But it is true.  Until the ACA became law, each healthcare provider (Physicians, nurses, pharmacists, social workers, physical, occupational and other therapists) worked independently of each other and in a silo.  As a result, there was fragmentation vs. collaboration among integral members of the treatment team and payers. Patients were discharged without proper discharge planning, so readmission's to the hospital were common. People were not adherent to the plan of care because they were not part of the design. Each of these system challenges caused costs to rise and patient and providers to be dissatisfied with the system as a whole as it was not working.

To change this, the ACA introduced incentives and disincentives mechanisms into the payment system that allows physicians and other members of the team to develop innovative ways to improve care coordination, transitions of care and effective discharge planning processes. Because of these strategies, we have began to see better outcomes in areas such as reduction in unnecessary re-admissions, the closing of gaps and barriers in care and more attention to the patient and their family, so they had a better understanding of the discharge plan and access to the resources they needed to be successful.

Today, we see doctors, nurses, therapists and others professionals making rounds together and taking the time to learn the value each member brings to the team. We see payers working collaboratively with providers to help complex patient transition across the healthcare system with help.  As a result, gaps which often led to costly medical setbacks are being closed.  Understanding these challenges and encouraging more collaboration allows each member of the team to work up to their full potential to address the needs of the patient.

Another change is that today, the patient and their family are included more and more as active members of the healthcare team. It has been recognized that none of the changes can work if the patient is not a central member of the healthcare team. This concept may seem logical that the patient is the primary person as they are the reason and the sole purpose for the healthcare system, but it is a relatively new concept, but one that is taking hold and being noticed by everyone. 

A tremendous amount of work is going into implementing systems to improve communications so that the patient has access to his/her medical records and can have a way to seamlessly communicate with the team when needed. Patients are being included in decisions about their care, and the team is listening to them. As a result, there is more buy-in from the patient which results in an increase in adherence to the plan of care, so outcomes are better.

The word about these changes is reaching the average consumer who is recognizing the important role they have to play. They also know they have more to pay as a result of rising insurance premiums, deductibles and other costs associated with their benefits so they understand that being a more savvy consumer is to their benefit. 

They are also realizing how difficult this challenge is, and how much they don’t know. They realize that the healthcare system is like no other entity consumers utilize in their daily lives.  Getting information on the cost of care, resources, and other services are not readily accessible to consumers or their providers. Today that is changing as insurance companies and provider’s set up patient portals that provide information that consumers can use to learn who is in their insurance network, how much they will need to pay based on their policy for a visit, procedure or a test and how they are doing with regard to their health and healthcare. Consumers now have access to many of the lab results or other diagnostic tests they have received. Having access to this information allows them to be more in charge and informed as to their health and healthcare and to share the information with providers they may see for various healthcare issues. As a result duplicate testing is down which has been a driver of healthcare costs. 

Through my experience as a patient with a serious medical condition, I learned that I was the only constant member of my healthcare team. It was I who was responsible for providing my history to each member of the team as they came in and out of my life to care for me. When I could not provide the information due to my condition, it fell to my husband.  We realized early on that we had to advocate for ourselves and try to figure out the system every step of the way. 

It was my responsibility to know all of my current and past medications, the dosages and why I was taking them. Many times, a doctor tried to put me on something that I had already been on, or that was not indicated on the protocol I was following as part of my treatment. It fell to us many times to tell the doctor that the medication or therapy he was considering had been tried or would not work with my treatment plan. Many would acknowledge this, but some would not be happy. Those who were not happy were referred to my Hematologist so they could have a discussion peer to peer. But I had to be the first line of defense. 

What I realized early on was that it was my role to recognize problems and to raise the red flag to cause everyone to STOP. It was my role to ask questions if my husband or I did not understand something. It was our role to tell a nurse, the aid, medical student, intern or resident to call the attending as we are NOT doing something that did not feel right. Many times I felt intimidated but overall I knew that if my husband or I did not say something, problems would occur.

As an experienced nurse, this was a challenge for me. I could not image how the average person who was sick functioned in the same situation. That is why I feel so strongly about writing this Blog, Nurse Advocate so I could educate and empower others to advocate for themselves.

But this is not enough. Every physician, nurse, pharmacists and another member of the healthcare team has to remember that WE all have an obligation to assist each patient as they navigate through the healthcare system. The average consumer does not have the education that members of the healthcare team has to advocate for themselves. They need help to do this, and it is up to the professionals in the system to do our best to educate and empower each consumer and their family. 

Today there are professionals who can work with a patient and their family when a healthcare crisis arises. Patient Advocates are in place to assure the person has a voice in their care. They are an objective professional who works exclusively for the patient and and or the family. They are paid for privately, so they do not have an obligation to the payer or the providers providing service. 

Advocates do not provide direct care, but instead inform, educate and provide the person with information so they can make informed choices. The advocate works with the patient and the healthcare team to ensure thee individual patient receives the care and the resources to meet their goals.

Yes, health care is changing and will continue to be in a disruptive state for a long time because changing the system is a monumental task. The most important thing we can all do is to pace ourselves, learn about the changes, stay involved and remain level headed throughout these disruptive times. 

We all know that change is never easy, but today with the internet, there is a wealth of information that can help consumers and members of the healthcare team better understand the new roles all are being asked to play.  I have provided some resources to help you and your family understand some of the strategies being put in to help transform practice so that healthcare is safe, effective, equitable and meets the needs of the individual consumer. Take time to read through these resources so that you are ready for the marathon. 

The Triple Aim: The Triple Aim was developed by the Institute for Healthcare Improvement to describe an approach to optimizing health systems performance. http://www.ihi.org/engage/initiatives/tripleaim/Pages/default.aspx

The Affordable Care Act is working:  Here are some statistics on strategies from the ACA and how they are improving access to health insurance, allowing improvements in quality and slowing healthcare costs. Take a minute to read. http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-is-working/index.html

Medicare.gov: Hospital Compare is a site that is helping providers to be more transparent as to what they do and how they do it. Hospital Compare shares insights into how new payment models are changing how healthcare is delivered to hospitals. https://www.medicare.gov/hospitalcompare/linking-quality-to-payment.html   To view other compare sites for physicians, home care, nursing homes and other settings, go to https://www.medicare.gov/hospitalcompare/search.html. These sites allow consumers can see how organizations they might choose compare.  Reviewing the information enables the user to make more informed choices.

Patient Survey’s: Just like other providers, healthcare providers want to know how they are doing and how they meant your expectations. Whenever you visit a doctor, a hospital or another service provider, you will probably get a survey soon after to complete.  It is important to take the time to fill out these and give your honest opinion as the information is recorded for quality improvement training. Also, providers are being paid for how well they do. Here is a link to learn more. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-instruments/HospitalQualityInits/HospitalHCAHPS.html

Patient and Family Hospital Advisory Boards: today many hospitals and organizations are developing patient and family advisory boards to better understand their patient’s needs. These boards are listened to and have helped organizations to improve the care they provide through honest and frank input. If you do a google search, you will find examples of hospitals who have these boards in place and the important work they are doing. Here is a case from Vanderbilt University. 

Shared Decision Making: Today there are many ways to treat medical or mental health decisions. Knowing the pros, cons and cost of these decisions is important as today, you as the consumer will have to pay for more and more of the care. What if you do nothing? Will it change the outcome? Understanding the diagnosis and the care that can be provided is important. Today consumers are sharing in the decision-making process. Shared Decision Making is a relatively new concept that is being employed by many physicians to provide patients and their caregivers with various choices to help them understand the choices and how the choices may impact their goals. To learn more visit this site, http://med.dartmouth-hitchcock.org/csdm_toolkits.html  Dartmouth-Hitchcock is one of the leaders in shared decision making.

Patient Advocate: When I was first diagnosed with the brain tumor, I was not thinking clearly and asked two colleagues for help. Both became my advocates and assisted my husband and myself in understanding what was happening, why it was happening and what were some alternatives. They did not replace the medical team but were there for my husband and me. They communicated with the team, so they understood the plan of care and helped my husband, and I get to the best place for my care. I honestly believe if it were not for these two professionals and my husband, I would not be here today. There is no doubt in my mind that everyone needs to have a patient advocate.  Many people say you would not go into a court of law without an attorney, so why would you enter the complex world of healthcare without a patient advocate. Here is an article I wrote for Nurse Together that explains an independent patient advocate http://www.nursetogether.com/nursing-beyond-bedside-independent-patient-advocates Not every person needs an advocate to address a healthcare problem. But when a need arises that is a challenge for your or a family member to handle, it 's nice to know one is available.

I hope this information is helpful and provides you with some useful information. If you have questions, please feel to email me and we can set up a time to discuss your questions or concerns. I might not have all the answers, but I can connect you with the people who do! 

Have a good week!