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.
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