Eating Right: Watermelon Bliss Salad

watermelon bliss salad Submitted by Cornell Colbert, Director of Food and Nutrition Services

Nothing says summer like watermelon. Nothing is as blissful as a watermelon salad artfully done. This week we kick of our art-of-summer recipes with the Watermelon Bliss Salad. It has just the right mixture of sweetness, tangy, nutty and creamy tastes and textures. Try it as your noon meal or the perfect accompaniment to your favorite grilled chicken, steak or burger. However you decide to try it, I’m sure you will find it blissful.

Portion for individual salad:
4 oz.      Shredded romaine lettuce
2 tbsp.    Diced red onion
2 tbsp.    Diced cucumbers
1/4 cup    Diced tomatoes
1/4 cup    Balsamic dressing
1 cup      Diced watermelon
1/4 cup    Blue cheese crumbles
1 tbsp.    Toasted Almonds

Directions
1. Place lettuce in a mixing bowl.
2. Add onions, cucumber, tomatoes and then dressing. Toss until completely coated.
3. Place lettuce and veggie mixture on a serving plate and pile as high as possible.
4. Top center of the salad with diced watermelon. Evenly distribute blue cheese crumbles on top of watermelon and lettuce.
5. Garnish with toasted almonds around the outer edges of the watermelon.

 

Recipe courtesy of Sodexo

Still booming (with babies that is)

Another day, another eight babies born at Wyoming Medical Center.

Wednesday, we reported on a respectable baby boom unfolding in The Birth Place. While baby flurries are common, nurses said, they are usually followed by a lull. No lulls have come, not since April.

“It’s just been one baby after the next,” said Kayla Golay, a registered nurse at The Birth Place.

“One mom goes home and her room is filled up with someone else.”

How busy is it? Consider these baby numbers:

— Since Monday, 32 babies have been born. The Birth Place typically delivers 14 to 21 babies a week.

8 babies were born Thursday, with another born overnight.

4 babies were expected Friday, including a set of twins — the second set of twins this week.

— As of Friday morning, 96 babies have been born in July – with more days to go. Compared that to July 2012 when 95 babies were born over the entire month.

— For the last few years, WMC delivered an average of 85 to 95 babies per month. They’ve delivered 100 babies in March, 95 in April, 103 in May and 101 in June.

When Sara Keeler came Tuesday, there wasn’t yet a labor room to put her in. Staff found her another room until she had to be taken to the Operating Room because her little guy, Peter Meike Keeler, decided he didn’t want to come easy. He was born 11:08 p.m. July 23, weighing 5 pounds, 8.9 ounces, and nurses took Keeler to her fourth and final room.

“My nurse was right with me the whole time,” Keeler said. “We knew it was hectic, but you could tell everyone was focused on us.”

The staff may be hopping, but we have plenty of care for all the babies and their families. In addition to the core staff of nurses, all The Birth Place staff is on call for this baby boom, said Cheryl Graff, clinical coordinator at The Birth Place and a WMC registered nurse for 31 years. “It’s all hands on deck and we absolutely love what we are doing.”

Golay agreed. Though she is busy caring for families and their new babies, this is precisely why she wanted to work in The Birth Place.

“It is always a happy time to see a new life come into this world.”

Finding my ideal weight: Should I or shouldn’t I?

Rarely am I willing to discuss anything as personal as my weight, even with close friends.  But today, I’m starting a blog.  I’ve thought about starting a blog about weight many times, but I figured there was really no reason to write about the weight I wasn’t losing.

When my office decided to start its own news site here at Wyoming Medical Center, I thought, “Why not?”  I had been thinking about taking the plunge and doing Ideal Protein anyway. Now seemed like the right time to start the diet and a blog to launch with the rest of our content.  I contacted Tamara Hawk, the director of our Weight Management program, and told her what I wanted to do.  A day or two later, she innocently told me how excited the Weight Management folks were for me to start.

Yikes.

I got cold feet.  I didn’t even really know the ins and outs of what Ideal Protein program entailed.  What if I failed?

I made an appointment with the Weight Management folks to get details.  It was a little scary, I’m not going to lie.  I would be allowed to eat three Ideal Protein packets per day and a whole bunch of vegetables.   Oof.  Then I considered the half a dozen times just this year I’ve started various “diets” for periods of days to weeks, never with any success.  My husband and I joined a gym in May, and while I’m proud of the strength we’ve both gained as a result of our 5 a.m. wake-up calls, it hasn’t moved the scale.

Let me go on the record to say that I do not like fad diets.  No funny red pepper cleanses.  No juice diets.  No starving.  And until now, no Ideal Protein.  But I decided that maybe this was just the structure I needed to get the weight off.

Mandy C. ParadeI weighed in on Tuesday and will weigh in again next Tuesday.   The nice ladies took my picture and promised it was cute, although I’m not so sure.  Maybe I’ll post it here someday. For now, I’ll show you a photo that inspired me to start this in the first place.  This is me at the parade a few weeks ago.  Sure, I look at myself in the mirror multiple times a day, but for some reason, I was still surprised to look at this picture and see me.  Is that what I look like?

Everything else in my life is going well.  I have a husband I absolutely adore seven years into marriage, a great job that I love, a wonderful group of friends and a very supportive family.  My weight feels like the missing piece in my life.  I know that it doesn’t have to be.

These first three days have been difficult.  I’m hungry.  I want a latte.  But they told me that the first few days are the hardest, so I’ll do my best to stick it out.

Here’s hoping my blog really is a “weight-loss” blog, and not just a “weight” blog.  My goal is to lose 38 pounds.  Wish me luck.

My Ideal Tracker

Pounds lost this week: n/a

Pounds lost so far: n/a

Pounds to go: 38

Power tip: Have a big salad for lunch, but save your Ideal Protein packet for an afternoon snack so that you don’t feel starved when you get home.

If you are interested in finding your ideal weight using Ideal Protein call the WMC Weight Management Program at (307) 577-2158.

Finding my ideal weight

Mandy Cepeda is the senior manager of community development at Wyoming Medical Center and contributor to The Pulse.  After graduating from the University of Wyoming, she started her career as a copy editor at the Casper Star-Tribune over 10 years ago.  While she decided journalism was not for her, she married one of the photographers, Dan, in 2006. They enjoy a lovely life together with their pound-puppy mutt, Maddie.  

Sports physicals are $35

Attention all volleyball, football and other fall athletes: Time is running out to get your sports physical. If your student athlete hasn’t yet got his fall sports physical, time is running out. They are available at Sage Primary Care for $35.

Physicians Assistant, Matthew Strand, of Sage Primary Care is now offering sports physicals for $35. A physical is required before participating in sports sanctioned by Natrona County School District.

Sage is located at 1020 S. Conwell St. in Casper. Hours are 8 a.m. to 5 p.m.

Walk-ins are welcome, or call (307) 265-8300 to schedule an appointment.

For more information on Sage, visit its website.

Members of the Wyoming high school all-star North and South teams compete in the 2013 Shrine Bowl at Natrona County High School in Casper. If your student athlete hasn’t yet got his fall sports physical, time is running out. They are available at Sage Primary Care for $35.
Members of the Wyoming high school all-star North and South teams compete in the 2013 Shrine Bowl at Natrona County High School in Casper. If your student athlete hasn’t yet got his fall sports physical, time is running out. They are available at Sage Primary Care for $35. (Photo by Dan Cepeda Photography)

Baby Boom: The Birth Place on pace to deliver 50 more babies than last year

baby hayden
Hayden John Maynard is one of 15 babies Wyoming Medical Center is caring for today, Wednesday, July 24. The Birth Place has been busy since spring, delivering more than 100 babies per month.

When Melissa and Ethan Dexter arrived at Wyoming Medical Center early Monday morning for the birth of their second child, it seemed like they were the only family in The Birth Place. The rooms appeared empty, they said.

Wednesday, Melissa took her new daughter, Rosalie Dexter, born at 7:55 a.m. Monday, for a walk down the hallway. Suddenly, every room seemed full. Continue reading Baby Boom: The Birth Place on pace to deliver 50 more babies than last year

Rev3 Glow Run

Wyoming Medical Center’s REV 3 GlowRun on July 19 drew 470 runners and walkers for the first time event in Casper.  As part of the Cowboy Tough REV 3 Adventure race, it started at dusk to encourage participants to dress up in their “brightest” or “flashiest” outdoor exercise attire.

Warm, windless, and free of most bugs found close to the river, the evening could not have been better. The start/finish area at Crossroads Park was decorated with several tents for registration, buying t-shirts and other race gadgetry.  There was even a large screen monitor for viewing ”Monsters Inc.” after the races.

Race participants ranged from experienced runners to those who hadn’t even let the thought of training enter their mind.

it was the enthusiasm of everyone taking part that made the night a successful one – that and the glowing runners. Team members slowed down to edge on slower ones. Mothers were running with baby strollers. Families were walking and running with kids of all ages.

It was completely obvious that a person didn’t have to be in top physical condition to take part in these races. Anyone could walk or run as fast as they felt comfortable. What stood out the most after the races had finished were the looks of accomplishment on people faces.  You had to look past the sweat and grimaces on some faces but those looks were there. For some, this was something that had done many times; just another race. For others it was their first time to line up and hear the horn starting them on their trek. Maybe next year will have to be my first time to hear that horn.

If you happened to miss the glow race, click through the photos, courtesy of Dan Cepeda Photography.

‘Paying Differently for Healthcare’ Booming hospital construction: Panel discussion, part 3 of 3

On July 18, Wyoming Medical Center teamed up with the Wyoming Hospital Association and The Wyoming Business Coalition on Health to lead a community conversation on healthcare in the Cowboy State. The conversation attracted nearly 200 doctors, hospital administrators, insurers, lawmakers and employers.

“Paying Differently for Healthcare – Finding the Right Incentives” featured a lecture by Dr. David Nash, dean of the Jefferson School of Population Health and a board-certified internist.  Nash believes that our current pay-for-service healthcare model raises costs for everyone without improving patient health.  Read about his remarks here.

The following is the third of three posts on the panel discussion that followed Nash’s remarks. Below, various stakeholders in Wyoming health care discuss a boom in hospital building, bundled payments and Patient-Centered Medical Homes.

Moderator Dr. Brent D. Sherard, medical director for Wyoming Integrated Care Network: As the medical care delivery system gets better in coordinating care and reducing length of stay, do we anticipate a continued hospital building boom or do we anticipate less need for hospital beds?

Vickie Diamond, president and CEO of Wyoming Medical Center: Well, the obvious answer is we would anticipate less need for hospital beds. But we’ve got how many million baby boomers that have had bad behavior in terms (of taking care of their health)? So we are still dealing with chronic disease, heart disease and cancer and we’re still are going to have to care for these patients. Can we do it in a more cost-effective way? Sure. And if we can manage them in a more coordinated way, I think our need for hospital beds will eventually go down.

We’ve actually reduced hospital beds in the last 10 years. In building new beds, I think it has to do with infrastructure in hospitals that tend to be very old. New beds do have to be to be built.

If you have better coordinated care, better chronic disease management, better patient engagement, we should be able to have fewer hospital beds.

Ryan Smith, CEO of Memorial Hospital of Converse County: I guess the thing that reduced hospital beds — not hospital buildings, not diagnostic imaging centers and surgery centers and buying surgery robots and all that other stuff – was when the PPS (Medicare Prospective Payment System) came along and we were incentivized to get patients out of the hospital. It’s the same concept here.

There may be some coordinated care and fewer hospital beds, but there is still going to be a lot of hospital spending. We are getting older … nobody’s getting healthier. It’s easy to say we aren’t going to spend money to build beds, but we are going to spend money for hospital services.

A panel of mixed stakeholders followed the remarks of Dr. David Nash on July 18 at the Ramkota.
A panel of mixed stakeholders followed the remarks of Dr. David Nash on July 18 at the Ramkota.

Moderator Sherard: As we look at going from a volume-based system to a value-based system, there are a lot of different payment methodologies that are being looked at. (Wyoming Medical Center) is working on developing a bundled payment program for orthopedic surgery. What are some of the more difficult obstacles you’ve had to address?

Dr. Craig P. Smith, board-certified orthopedic surgeon practicing with Casper Orthopaedics and Wyoming Medical Center: We are really trying to find out what the costs are and sort them out in a meaningful way to get people to change their behavior to get better quality care at less cost.

You think that would be simple to do, but when I look at the information that was presented to me when we first started talking about this over a year ago, it was pretty much useless as far as being helpful for me to help out. The most recent information that I look at is now becoming somewhat helpful in ways of showing me in my own personal practice patterns where you could cut costs and not impact patient care.

There are variable cost issues that I actually think are going to be easier to deal with than the system costs. That’s something we don’t have a choice in; It’s coming down the pike, at least for certain kinds of physicians. I’m going to have to deal with it sooner than a lot of others, but I know it’s coming to everybody. For me personally, what’s been hard is just the time commitment. That may seem like you should just make the time, but I’ll be frank, it’s hard to make the time when I look at the hours I work. I’d probably make more time if the incentives change. … In the current model, it’s hard for me to do that.

Diamond: Let me tell you what we are trying to do. We are doing a single-joint bundled payment … with Medicare. We’ve been working for a year, and we have a lot of people working on getting this data. Medicare dumps its data, but first you have to hire somebody who will be able to figure out what that data is telling you, because you have absolutely no idea what that data says. …

The bundle we’re looking at is where the hospital assumes the risk and we can gain share if we can make any money at the end of the procedure. We get 2 percent (from Medicare) before we would go into the bundle and we have a three-year commitment. The way tMedicare has built the system, there are far more sticks than there are carrots.

The biggest challenge has been, once you get the data and you can zero in on some of the variation and the cost, where is the evidence that says this is better than that? How do we know this is better because there isn’t always evidence to say that it is, so we are going out and looking at best practices…

If you really want to do it the best way, you’ve got to tune the patient up before they come in so they can have the maximum experience when they leave.  We may say the best place for the patient is in X facility or in X physical therapy, … but in the Medicare program, the patient has a choice. But maybe it’s  a choice that doesn’t really meet the outcome. …

But we hope to be doing bundled payment because we have to get our toe in the water. Our problem is getting our systems attached to real-time data so we know where we fall into that whole data stream. I have to give compliments to (Dr. Craig Smith) because he says he hasn’t had a lot of time. But he has been our champion and he really has wanted to make this work because we all know it is coming.

…. We’ve got great people working on it, and it is a struggle, but I think we are getting there.

Dr. Nash: Bundled payments for the single joint is a great training ground for what we all think will be more bundled payments — pretty discrete, small number of operators, good measures of outcome. So it’s a good place to cut your teeth.

I wanted to pick up on one thing you said: I think that total amount of money will come down. I’m curious about these Medicare shared savings plans – the ACOs. My view on this is probably heretical, which is I would avoid these totally. And the reason is I just have this sinking feeling that when you step back and say, “I’m going to share savings with Medicare,” wait a minute. They control all the rules. Next year’s ratio is going to look different than this year’s. …

So, it’s great to experiment, practice, cut your teeth on single joint. So, pay-for-performance, single joints (bundle payments), more capitation (models) for primary care, Patient-Centered Medical Homes and all of the sudden – three or four years down the road — you are practicing more of a population-based kind of care. That’s the spectrum that we see here.

Moderator Sherard: I would wonder if in Wyoming we have a big enough concentration of Medicare lives to make it work. I think you have to have 5,000 lives and it’s pretty hard to find that within a system in Wyoming.

Moderator Sherard: (To the panel:) What are some of the most difficult options you’ve had to address with patient-centered medical homes?

Ryan Smith: So we are just get started with the Patient-Centered Medical Home. One obstacle is the environment to practice it in. We’re currently working on building a 25,000-square-foot medical office building so we can construct space that is conducive to practicing a Patient-Centered Medical Home.

Another obstacle is getting the data we need to get the information out of our (Electronic Medical Record) we need to get out to make it successful, and doing it all in the context of moving to this value-based system.

But it still feels a lot like the volume system. Until the payers tell us how we are going to be paid for being in that system, we’re nervous about it. It’s the chicken or the egg scenario. Do we do it and hope they pay us for it, or do they tell us how they are going to pay us for it and then we do it? We don’t know any of that.

Previous posts: From volume-based to value-based payments” and “Waiving the magic wand”

‘Paying Differently for Healthcare’ From volume-based to value-based: Panel discussion, part 2 of 3

On July 18, Wyoming Medical Center teamed up with the Wyoming Hospital Association and the Wyoming Business Coalition on Health to lead a community conversation on health care in the Cowboy State. The conversation attracted nearly 200 doctors, hospital administrators, insurers, lawmakers and employers.

“Paying Differently for Healthcare – Finding the Right Incentives” featured a lecture by Dr. David Nash, dean of the Jefferson School of Population Health and a board-certified internist.  Nash believes that our current pay-for-service healthcare model raises costs for everyone without improving patient health.  Read about his remarks here.

The following is the second of three posts on the panel discussion that followed Nash’s remarks. Below, various stakeholders in Wyoming health care discuss switching from a volume-based payment system to a value-based system.

Moderator Dr. Brent D. Sherard, medical director for Wyoming Integrated Care Network: How can hospitals, physicians and other care providers go from a volume-based to a value-based reimbursement system?

Vickie Diamond, president and CEO of Wyoming Medical Center: We’ve got to have the data.

We have been working on a bundled payment initiative but just getting the data — sorting that data and knowing what to do with that data — is probably the biggest obstacle. If you’re going to move to value, you’ve got to make sure you know where your costs are, why you’re doing things the way you’re doing them, why you have variation in order for you to get those costs out of the system.

So it’s really bringing the people together and really sitting down at the table and saying, “Ok. How can we get better value out of this?” From my perspective, it’s a massive education, it’s amassing data and it’s also knowing that Wyoming — believe it or not Dr. Nash — doesn’t have managed care. So we’re not used to having those kinds of data points. We need to have that expertise in our state so that we can start creating more value in our care.

Ryan Smith, CEO of Memorial Hospital of Converse County: I think the best way to get there, and the most timely way to get there, is through payment –pay for value and then you’ll get it. Otherwise, we are just going to keep doing what we’re doing.

It seems to me it’s the equivalent of asking McDonald’s when they are going to stop selling the Big Mac … and start selling salads. They have to be incentivized to do that. I think it’s the same for us. We don’t know how to play this game unless someone plays it out for us.

We are trying. Those are all good things and we try to do them. We try to meet the core measures, we try to provide this safe effective patient-centered, timely, equitable,  efficient care. It’s just a convoluted system. But when we finally start getting meaningful payment for value — not just 2 percent of our Medicare payments but 20 percent of all of our payments — then we’ll figure it out pretty fast. We’re pretty smart people and we can pivot, but we have to be incentivized to do it first.

That comes back to getting big governmental payers involved in more significant ways, which lobbying is probably going to prevent from happening.

Moderator Sherard: One of the things we’ve done is … we have 28 Patient-Centered Medical Homes in Wyoming … working to become National Committee for Quality Assurance certified.

We have been meeting with payers now for probably a year and a half. They have been very receptive about looking at some sort of incentivization, not only into our Patient-Centered Medical Homes, but to those practices that can start providing quality data out of their practices. … Probably in four or five months, I’ve seen quality data from some of our practices, pulling out things that seem really simple — like how many patients smoke or how many patients do you have in your practice. Things we couldn’t do very easily prior to the (Electronic Medical Record), and quite frankly, it’s still a challenge. …

I’m a firm believer that if you can start reporting quality, see about what you need to do about your own personal quality, that’s what’s actually going to start driving costs down.

Dr. Craig P. Smith, board-certified orthopedic surgeon with Casper Orthopaedics and Wyoming Medical Center: I would just like to comment about incentives and making it a real difference. This 2 percent, for example, on Medicare if you do X, Y and Z.

Well, in our office, we’ve found that instituting X, Y and Z makes the time the patient waits and gets in and out of the room after they’ve been seen 10 minutes longer. It’s substantial. It’s not worth it for us to do that in the current model. We wonder why we are even doing it. We’ve considered even stopping.

It’s got to be a real incentive. You should still be doing things for the right reason, but the incentive is going to have to be there in a significant way.

Linda Witko, assistant city manager and chief information officer for the City of Casper: I’d like the dialogue to become one where the payers — not just the insurance companies, but the payers, from the standpoint of employers because employers are the largest body of payers for health care in this country — for the payers and the providers to sit down together and talk about what’s important to them. And what’s important to me, of course, is that my employees get quality health care, and if I’m going to pay for something, I’m going to pay for something to be done, but I’m not going to pay for it to be done twice.

I’m going to make sure that (employees) are getting not only the physician’s recommendations, but they are also having an opportunity to ask questions and to participate in determining what options they choose. … My question has always been: Are patients given the option to look at less invasive treatments that may be, in fact, a very positive way to continue working and continue living versus jumping right to surgery?

I want to ask those questions but I can’t ask them without having the opportunity to sit in a room … with the people that are making those decisions and providing that care. … When I go back to the employee group, and when I put out information about this is what you do if you have this particular issue, this is where you go to get your information and this is how you talk to your doctor and these are some of the options and this is what our health plan will pay for and this is what our health plan won’t pay for.

Moderator Sherard: So what I hear you saying is, as an employer, you’d like to have more say in how that patient is taken care of because you are footing the majority of the bill.

Witko: That is correct. And a good example is we can identify from our workers’ comp data where we’re seeing the most workers’ comp injuries.

Let’s just say that most of the workers’ comp injuries in one work group tend to be back injuries. Then, I want to be able to have someone come in and evaluate our work place, help us do back strengthening programs and target that particular work group, so I can start addressing some of those workers’ comp costs.

It’s not just that I want to send my employees to a physician and pay for a physician’s care. I want to get involved in programs that actually help them avoid them having to go to a physician. But I need professionals from different areas of the healthcare industry to put that kind of a program together.

Dr. Michael Tracy, a primary care physician in Powell: I think that it actually requires a bit of a paradigm shift to try to figure out how to make that jump from fee-for-service to value based. If you think about the three aims of the (IHI) triple aim (Initiative), the first is to improve the individual patient experience, the second is to improve population health, and the third is to decrease the per-capita cost of health care. There are a lot of people in this room who are probably here today because they feel that that is exactly what has to happen.

I kind of question, in the current system, I don’t think the incentive is there for the drivers of the healthcare system to decrease the per-capita cost of health care. It needs to happen, it’s just not part of the current system.

Dr. Smith: For health insurance — the most important insurance you have — you have your employer provide it for you. (Employers) are thinking about a group; They aren’t thinking about you and what your needs are, what your problems, what your assets are, what you expect.

For any other successful insurance product, it’s really not done that way. You don’t let someone else buy car insurance or homeowners insurance for you. You do that yourself.

I know things come to the table that you don’t control. But for things you do control, I certainly think that would incentivize the population to … raise that from 3 percent (of the population that doesn’t smoke, exercises three times a week, is not obese) to a number much higher. We don’t really do that in our current model. The responsibility isn’t there for a lot of people to do that.

Dr. Nash: Large self-insured employers are doing an awful lot with their employees to lower their total cost burden. Not sure it’s exactly right to say that it’s not individually focused.

Let’s take anyone of the major national organizations on the private sector that are self-insured. They are doing everything through health risk assessments, care coordination, on-site care. Through the national organization, the Care Continuum Alliance, the Boeings, the Wal-Marts, etc., all come to compare notes on the impact of their patient engagement programs.

… Let’s leave the meeting with the clear understanding that the evidence would fill this room with America’s private sector companies doing battle on the healthcare front to lower costs through patient engagement. … Those also include city governments who are also members of the Care Continuum Alliance because they, too, have all kinds of healthcare challenges.

Wendy Curan, senior director for care delivery and coordination at Blue Cross Blue Shield of Wyoming: We have been talking very closely with Wyoming Integrated Network about Patient-Centered Medical Homes. Blue Cross Blue Shield supports that concept fully as the way to begin the transition of behavior and treatment in patients and better coordination of care.

We, in fact, have already set out some incentive payments to some of the practices that are working with us, and with some of our technology to help gather information, we will continue to see that grow. We’ll continue to work with the 28 practices because we absolutely believe that’s where we need to start. Not just to go to providers to say, “Do this.” But to say, “How can we help you help us? How can we do this together?”

We know we need to change things. We know payers hold the keys to a lot of those incentives, but in this state, we have to have collaboration if any of us are going succeed.

Moderator Sherard: One of the things that we’ve heard from the payers is, “Ok. We’re paying you guys and we thought we were paying you for quality. So what’s all this quality talk all of the sudden?”

I think that is a valid question. The issue really is we’ve never been able to measure outcomes out of physician practices and not real well coming out of the hospitals either. We have just gone to (Electronic Medical Records) in Wyoming in maybe the last decade and there are still a lot of issues trying to get that data out of them. I think the EMR has allowed us to do some more of the data collection and really understand the quality we are producing. I think from a physician perspective, quality is very important to me to know that I’m practicing the very best medicine.

 

Previous post: “Waiving the magic wand”

Next post: “Booming hospital construction”

‘Paying Differently for Healthcare’ Waving the magic wand: Panel discussion, part 1 of 3

On July 18, Wyoming Medical Center teamed up with the Wyoming Hospital Association and The Wyoming Business Coalition on Health to lead a community conversation on healthcare in the Cowboy State. The conversation attracted nearly 200 doctors, hospital administrators, insurers, lawmakers and employers.

“Paying Differently for Healthcare – Finding the Right Incentives” featured a lecture by Dr. David Nash, dean of the Jefferson School of Population Health and a board-certified internist.  Nash believes that our current pay-for-service healthcare model raises costs for everyone without improving patient health.

Nash’s book, “Demand Better: Revive Our Broken Healthcare System,” is worth a read for anybody interested in the rising cost of health care and what might be done about it. You can also read about his Casper remarks here.

This post is about the panel discussion that followed, featuring various stakeholders in Wyoming health care – doctors, hospitals, insurance representatives and employers. It is the first in a series of three posts about the discussion, each including the full transcript of a particular topic. The conversation was meant as a starting point for discussion in the state, and we think it is important to present it in full.

A panel of mixed stakeholders followed the remarks of Dr. David Nash on July 18 at the Ramkota. Pictured, from left, are Moderator Dr. Brent D. Sherard, medical director for Wyoming Integrated Care Network; Dr. David Nash, dean of the Jefferson School of Population Health and a board-certified internist; Wendy Curan, senior director for care delivery and coordination at Blue Cross Blue Shield of Wyoming; Vickie Diamond, president and CEO of Wyoming Medical Center; Dr. Craig P. Smith, board-certified orthopedic surgeon with Casper Orthopaedics and Wyoming Medical Center; Ryan Smith, CEO of Memorial Hospital of Converse County; Dr. Michael Tracy, a primary care physician in Powell; and Linda Witko, assistant city manager and chief information officer for the City of Casper.
A panel of mixed stakeholders followed the remarks of Dr. David Nash on July 18 at the Ramkota. Pictured, from left, are Moderator Dr. Brent D. Sherard, medical director for Wyoming Integrated Care Network; Dr. David Nash, dean of the Jefferson School of Population Health and a board-certified internist; Wendy Curan, senior director for care delivery and coordination at Blue Cross Blue Shield of Wyoming; Vickie Diamond, president and CEO of Wyoming Medical Center; Dr. Craig P. Smith, board-certified orthopedic surgeon with Casper Orthopaedics and Wyoming Medical Center; Ryan Smith, CEO of Memorial Hospital of Converse County; Dr. Michael Tracy, a primary care physician in Powell; and Linda Witko, assistant city manager and chief information officer for the City of Casper.

Moderator Dr. Brent D. Sherard, medical director for Wyoming Integrated Care Network:  If you could wave a magic wand, what characteristics would a new payment model have and how would it look in Wyoming?

Dr. Michael Tracy, a primary care physician in Powell: I think there are a lot of things to this question, but one of the things I think would be good would be to be in a situation where we were not just rewarded for the volume of things we do, but more for the overall population management like Dr. Nash was talking about.

Right now there is very little recognition for non-face-to-face visits. And if you think about what that means in Wyoming, I live in Powell and I have patients who live as far away as Thermopolis, Worland and Meeteetse and a couple of people who have moved away but still consider me their provider, one in Evanston. Really face-to-face visits are not always possible, nor should they be. That’s a big part of the system we need to look at in Wyoming.

I think access and efficiency is something in the primary care world that would be good to have rewarded. One of the things I think we are going to be talking about throughout this panel discussion is the ability to get in to see your primary care provider, and when you do, does it happen efficiently? … I appreciate the fact that when people take the time out of their days to come and see me, they are taking time away from their productivity.

I think access and efficiency is something that would be rewarded in the payment system in addition to the quality metrics that we talked about.

Vickie Diamond, president and CEO of Wyoming Medical Center: If I had a magic wand, I would really like to see a patient-centric system where all the providers and everybody are focused on population wellness, and where the payer system  — regardless of how you’re paying — rewards for that population health.

But the question is not only how does the provider get paid. It is: What is the individual responsibility of John Q Citizen in order to actually help with that population health? So it’s the choices that we make.

It would be nice if we all moved in the same direction regardless of if you are business that pays for health care, whether you are a provider of health care, but it’s also you as the public. What are we going to do to make our healthcare expenses less?  For me, it’s moving forward together for the wellness of our country, the health of our children.

Moderator Sherard: Vickie (Diamond), what would be a way to get the public more in touch and in tune with your comments, because I think you are right on?

Diamond: I think we have to do a lot of education. I think our businesses have to reward — I’m not going to say penalize, I’m going to say incentivize — our employees to be healthy. And that usually comes with out-of-pocket expenses, that’s really where it drives it home.

We in our separate entities — whether we are a business or a provider of care — how do we come together? In our population data, do we know if the City of Casper has more diabetes and hypertension than, say, McMurry Enterprises?  … If we have that information, why aren’t we pooling our resources to work together to actually improve diabetes or hypertension in that population? Meanwhile, we are paying for care separately with a lot of office visits instead of asking: What are we going to do here in Casper to provide diabetes care in our community?

Dr. Craig P. Smith, board-certified orthopaedic surgeon practicing with Casper Orthopaedics and Wyoming Medical Center: If I had a magic wand, it seems we don’t talk a lot about the responsibility of the patient. I know there are a lot of factors that play into that, socioeconomic and such, but if we look at any other kind of insurance that is provided, that is taken into account. If you drive fast and have a lot of accidents, that is going to cost you more. But if you don’t exercise, you smoke and don’t take your medication … somehow some houses end up footing the bill for that.  To me, being in a private practice seeing patients, boy I wish I had that wand.

Moderator Sherard: We’ve all existed in our silos, and one really glaring silo is the lack of coordination between public health services and clinical health services. The state of Wyoming has tremendous number of public health programs … all across the board to local health programs. … I think that’s an opportunity as well to integtrate population health and public health services with clinical services.

Ryan Smith, CEO of Memorial Hospital of Converse County: Unfortunately, I was the CEO that Dr. Nash was referring to that drove him on the Kenai Peninsula to the airport (Read about Dr. Nash’s encounter in Kenai here.)

… I’m sure that he’ll be happy to know that the physician smashed that seven-figure income guarantee to go to the Kenai Peninsula which does prove, I think ,that it is definitely a broken system. They also did a ribbon cutting last week for a brand new radiation oncology center on the Kenai Peninsula, so the carnage continues.

And it continues even in the small towns where I work now, like Douglas, Wyo., where we just purchased a $2 million da Vinci SI Robot to do surgeries for hysterectomies, single-side hysterectomies and gall bladder surgeries in a town of 6,000 people.

If we had a magic wand, probably one of the first things we would do is wand away the $500 million worth of lobbying money that goes to keeping the current payment system in the status quo. … We’d get rid of some of the perverse payment incentives that are being held around by Medicare, Medicaid and others.

Now, when we go back to Washington, D.C., we listen to people like Steven Rattner talk about that there is no way in heck this is ever going to change because, in the court of public opinion, people like their health care the way it is right now. It’s highly unlikely with the Medicare patients who are entering that system — who have put in about $100,000 to that system and are going to reap benefits of over $300,000 from that system — that that payment model is going to change.

We want it to happen, we want to be part of that, but it seems like it’s going to be tough to do.

Diamond: I think Ryan hit it right on the head. … We are in a fee-for-service system and then you add a population of 500,000 people in the state of Wyoming, and we know in order to be able to take risk you have to have 500,000 covered lives. Otherwise … one patient can take you right out. So, how do we adapt that to Wyoming?

We as the providers get beat up that we’re too expensive, we do too much this , we need to be in the new system. But we’ve got to come up with a strategy for states like Wyoming and rural states. … We have to figure out a way to do this in Wyoming without burdening the provider with all the risks.

Wendy Curan, senior director for care delivery and coordination at Blue Cross Blue Shield of Wyoming: Following up on Vickie (Diamond’s) comment: Do we know what health care costs in Wyoming? Do we know where the sickest people are? Has that information been collected, and what do they do with it?

I haven’t been working for Blue Cross Blue Shield for very long. Before that I spent some time working on the provider side. My biggest complaint was always, “My gosh. (Insurers) have all the claim information in the world, they should know everything. And yet, they wouldn’t share.”

Well, when I went to work there, it wasn’t that they wouldn’t share, it was they weren’t doing anything much more with data analysis and looking at where costs were than anyone else. We’re making a big effort now to sit with our hospitals and saying, “Look we’ve done a lot of work on getting down to risk-based costs for your patients and comparing them with where they are at other places, but we’ve got a lot of work to do until we can sit down with some sort of valid data and saying this is the cost of care here and its different here and its different here.”

My magic wand would be put toward having the kind of information that informs those kinds of decisions.

Next posts: From volume-based to value-based payments” and “Booming hospital construction”

‘Paying Differently for Health Care: Finding the Right Incentives’

In his remarks July 18 at a health care conference in Casper, Dr. David Nash told a story about his visit to the Kenai Peninsula in Alaska.

The hospital’s young  president, Ryan Smith, was driving Dr. Nash to the airport after a visit with the board of directors. Smith (now CEO of  Memorial Hospital of Converse County) pointed out the moose eating at the side of the road. Then, Smith excitedly told Nash about the new fusion-trained orthopedist who’d be coming to the peninsula in a few months.

“Let me get this straight,” Nash said. “In your 50-bed, critical access hospital, you’re bringing a spinal-fusion, fellowship-trained orthopod?”

Oh yeah, Smith answered. It would be the hospital’s highest ever DRG (diagnosis-related group). The surgeon had a seven-figure guarantee in the first year.

“A lot of moose must need spinal-fusion surgeries,” Nash told the president.

“So, who’s going to pay for that doctor?” Nash asked the 200 doctors, hospital staff, insurers and employers at the conference. “You and I know we are going to pay for it.”

Dr. David Nash speaks during “Paying Differently for Healthcare – Finding the Right Incentives” on July 18 at the Ramkota in Casper.
Dr. David Nash speaks during “Paying Differently for Healthcare – Finding the Right Incentives” on July 18 at the Ramkota in Casper.

Dr. Nash, dean of the Jefferson School of Population Health and a board-certified internist, was the featured speaker at “Paying Differently for Healthcare – Finding the Right Incentives,” a conference sponsored by the Wyoming Medical Center, the Wyoming Hospital Association and the Wyoming Business Coalition on Health.

Nash is the coauthor of “Demand Better: Revive Our Broken Healthcare system,” a book which argues that to fix America’s ballooning healthcare budget, we must stop paying for service but paying for outcomes.

In Philadelphia where he lives and works, there are five medical schools and 90 hospitals within a 25-mile radius of his office.

“If you have to walk more than two blocks for a cardiac cath, it’s incredibly inconvenient,” he said. “And all those beds, we fill them.”

For 50 years, American health care has operated under the mantra that more is better — more buildings, more patients, more beds. Providers charge for every visit, every procedure, every test – regardless of whether a patient’s health improves. The more we do, the more we get paid.

When you increase capacity for health care – building new specialty hospitals, for example – it doesn’t lower prices for consumers. Instead, providers refer patients to use their services. The net result is more tests, more procedures and an overall increase in health care costs from everyone in the system.

As a country, we spend 20 percent of our Gross Domestic Product on health care, compared to just 4 percent for defense. And what has it gotten us?  This year, the Journal of the American Medical Association, ranked the United States below Slovenia in quality of life as measured by health and other global measures.

“We are not even in the top 20 nations worldwide,” Nash said.

The future, Nash argued, is in population health.

Consider that 85 percent of population’s health is determined by social factors – violence and crime in the community, poverty, family health histories, obesity rates, etc. Only 15 percent is affected by a doctor’s “laying of hands” on a patient.

Of all the money spent on research, surgeries and chemotherapy treatments, a nationwide smoking cessation campaign made the biggest strides in the war on cancer, Nash said.

If America is to get a handle on its debt problem, we must get a handle on our healthcare spending, he said. That means moving from volume to value and convincing doctors and hospitals that more is not better.

Nash identified four pillars of cost containment.

  1. Tie payments to outcomes.
  2. Bundled payments for physicians and hospitals.
  3. Reimbursements based on coordination of care across providers.
  4. Holding providers and hospitals accountable for results.

It’s not an easy proposition, Nash said, and it requires buy-in from every stakeholder – from doctors to hospitals to patients. Consider that just 3 percent of Americans don’t smoke, are not obese, wear their seatbelts, eat the recommended amounts of fruits and vegetables and have a healthy body mass index, and you can see the sharp challenges ahead.

But the consequences of inaction are even more painful, Nash said.

For more, read Wyofile’s report on the conference, “Wyoming’s medical community confronts rising healthcare costs,” or the Wyoming Business Report’s article, “Speaker: ‘Payment for health care must change.”

A panel discussion with hospital CEOs, insurers, employers and doctors followed Nash’s remarks. We have transcribed the discussion and published it in three posts: “Waiving the Magic Wand,” “From volume-based to value-based” and “Booming hospital construction.”