Steven M. Berkowitz, MD

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KEYNOTE SESSION Achieving Success with
Reform Are You Ready for the Game?
Steven M. Berkowitz, MD SMB Health
Consulting Austin, TX steve_at_smbhealthconsulting.co
m 512-415-6095
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Whats New with Health Care Reform?Same Old Wine
in a Brand New Bottle ?
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U.S. Health Care Organizational Chart
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Whats New with Health Care Reform?
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• You can always count on Americans to do the right
  thing
• after theyve exhausted all the
  other possibilities !!
• 
  Winston Churchill

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People do not change until the pain of staying
the same exceeds the pain
of changing.
Anonymous
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The Health Care Team

• Medicine is a Team effort.
• ..Why do we insist on playing Solo !

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The Health Care Team

• Medicine is a Team effort.
• ..Why do we insist on playing Silo !

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The Conundrum of Quality in Health Care
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Quality Challenges for a Ticket to the Game

• 1. Embrace Data Transparency
• Implement Evidence-based practices
• Excel at Pay for Performance
• 4. Add the Secret Sauce !!

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Quality Challenges for a Ticket to the Game

• 1. Embrace Data Transparency
• Implement Evidence-based practices
• Excel at Pay for Performance
• 4. Add the Secret Sauce !!

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Value-Based Purchasing

• The increasingly informed consumer will make
  health care decisions on the basis of VALUE

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Read all about it !! April 2005
Data Transparency
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This is Your Life !! Data Transparency in Action
Data Transparency
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Pennsylvania Coronary Artery Bypass
Surgery 2008 - 2009
Released May 2011
Data Transparency
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Use of Public Performance ReportsA Survey of
Patients Undergoing Cardiac SurgerySchneider,
JAMA May 27, 1998

• 58 of patients probably or definitely would
  change surgeons if their doctor had a higher than
  expected mortality rate the previous year
• 1 knew the rating of their surgeon

Data Transparency
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CABG Mortality in Pennsylvania Results !
Data Transparency
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The New York State CABG Experience Chassin,
Health Affairs, 2002

• 41 reduction in mortality in first four years
• Mortality higher in facilities with low volumes
• Reduction in hospitals doing CABG
• Reduction in physicians performing procedures
• 27 surgeons ceased operations in NY
• Their combined mortality was 11.9
• ( NY state average 3.1 )

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Wisconsin
QualityCounts Report on the Safety of Hospital
Care Released January 2003
Data Transparency
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The Wisconsin Experience
That which is measured, tends to improve. That
which is measured publicly, tends to improve
faster.
What we concluded was that even when hospitals
know their performance is not good, that's not
sufficient motivation for them to do something.
Making it public made a big difference in
motivating them to improve.

Judith Hibbard, Health Affairs 2003
Data Transparency
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Core Measures Heart Attack Heart
Failure Pneumonia
Surgical Care Improvement
HCAHPS
Data Transparency
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CMS Core Measures- 90th Percentile
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Goal 100 Compliance !!
Core Measures Heart Attack Heart
Failure Pneumonia
Surgical Care Improvement
HCAHPS
Data Transparency
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Core Measures Heart Attack Heart
Failure Pneumonia
Surgical Care Improvement
HCAHPS
Standard of Care ? !!
Data Transparency
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Data Transparency and Accountability

• Transparency is the best thing thats happened to
  advance quality since antibiotics..

Data Transparency
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Why are CMS Core Measures Important?Serving
Multiple Masters

• Evidence-based ? good
  for the patient
• Publicly available
  ? marketing/ PR
• Effect
  reimbursement ? dollars
• Ultimately, SURVIVABILITY in Health Care Reform

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Exposure to and Use of Quality InformationPercent
Who Saw and Acted Upon the InformationChoice of
Hospitals
Kaiser Family Foundation, October 2008
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• If the other guys getting better, then youd
  better be getting better faster than that other
  guys getting better
• Or youre getting worse.
• 
  Tom Peters

Change
Data Transparency
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Data Transparency and Accountability

• As transparency matures, it will redefine
• WHO is your competitor
• How can your organization work together to
  improve ?

Data Transparency
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Steves Three Rules for Data

• 1. The data is significant, whether it is
  significant or not.
• 2. A low score almost always points to a real
  issue.
• The biggest gain in performance improvement
  occurs when going from NO data to ANY data.
• Involve ALL stakeholders in the
  performance improvement process
• There is NO reason to blind the data !!!

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Hospitals and Physicians Working as a Team

• Share the Data !
• Decrease the Variance !

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Hospitals and Physicians Working as a Team

• Large variances continue to exist amongst
  physicians and hospitals
• Variances can and do lead to differences in
  management, treatment, and outcomes for the
  patient

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Hospitals and Physicians Working as a Team

• Data , not an Indictment !!

Data is NOT Diagnostic !!
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Hospitals and Physicians Working as a Team

• The great majority of outlying physicians are
  good physicians who have developed a particular
  style of practice which can be improved !

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The Future of Transparency(Health Care, too) !!
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The Future of Transparency(Health Care, too) !!
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The Future of Transparency(Health Care, too) !!
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The Future of TransparencyHealth Care, too !!
Accountable Care Organization
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Questions for the Leadership Team

• Does your organization
• embrace data transparency ?

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Quality Challenges for a Ticket to the Game

• 1. Embrace Data Transparency
• 2. Implement Evidence-based practices
• Excel at Pay for Performance
• The Secret Sauce

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Implementing Evidence-Based Medicine What Can we
Learn from the Airline Industry ?
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What Can we Learn from the Airline
Industry?Teamwork Guidelines and Checklists
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Our Greatest Challenge in Clinical Medicine
Eliminate the DEADLY Delay !!
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The Deadly DelayFrom Clinical Trials to
Clinical Practice
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Core Measures Acute Myocardial Infarction
Heart Failure Pneumonia
Surgical Care Improvement
HCAHPS
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Core Measures Acute Myocardial Infarction
Heart Failure Pneumonia
Surgical Care Improvement
HCAHPS
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Beta-Blocker for Acute MI The Evidence is
Published
31 Years Ago !!
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Where Do We Find the Best Practices ?Examine
Your Own Specialty Literature
Implement the Guidelines Recommended by your OWN
Specialty Society
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Guidelines for Guidelines

• There will be MORE guidelines in clinical
  medicine
• Guidelines were NEVER intended to apply to all
  patients and do NOT take the place of
  individual physician judgment
• Expect physicians to occasionally deviate from
  guidelines in the daily practice of prudent
  medical care
• When so
• DOCUMENT In the medical record
  that
• The patient was seen
  and evaluated
• The options were
  thoughtfully considered
• The best clinical
  judgment was used
• Discussed with
  the patient

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What Can we Learn from the Airline Industry
? Elimination of Ambiguity
the elimination of ambiguity is consistently
cited as a key factor in protocol success and
safety

• Degani and Weiner 1993

Most medical guidelines are based upon ambiguity
as a guiding principle of protocol development
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ExampleOxytocin Treatment GuidelinesACOG 2006
Compendium

• Any of the low or high dose regimens
• outlined in table 2 are appropriate
• (0.5 6 mU/min every 15-40 min)
• Each hospitals OB/Gyn department should develop
  guidelines for preparation and administration of
  oxytocin
• The uterine contractions and fetal heart rate
  should be monitored closely

Evidence-Based Medicine
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ExamplePostdates GuidelinesACOG 2006 Compendium

• Women with post-term gestations who
• have unfavorable cervices can either
• undergo labor induction or be managed
  expectantly
• Delivery should be effected if there is
  evidence of fetal compromise.

Evidence-Based Medicine
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How to Land a 747 in a Strong Cross Wind(Had
It Been Written by ACOG)

• Use any settings of the planes
• instruments you feel like
• Every airline and pilot can do it
• differently
• Be really careful as you get close to
• the ground Steve
  Clark, MD

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Do Guidelines Help or Hurt?
Yeah, but Pilots do not have to worry about
Malpractice Suits
Obstetrician, Texas
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Do Guidelines Help or Hurt?
Yeah, but Pilots do not have to worry about
Malpractice Suits
Youre Right, We Just Die !!
Obstetrician, Texas
Famous Pilot / Dog
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Do Guidelines Help or Hurt?
We keep missing the point.. Simply
put Evidence-based Guidelines reduce
adverse outcomes !
Evidence-based Guidelines improve patient care !
Evidence-Based Medicine
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Questions for the Leadership Team

• Does your organization
• implement best practices ?

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Quality Challenges for a Ticket to the Game

• 1. Embrace Data Transparency
• 2. Promote Evidence-based practices
• Excel at Pay for Performance
• Add the Secret Sauce !!

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Job One !!

• There will be a focus on Cost Control like we
  have NEVER seen before in our careers

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Cost ReductionThe Role of Successful Transition
Management
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Cost ReductionThe Role of Successful Transition
Management
????
Payors
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Cost ReductionThe Role of Successful Transition
Management
Any decrease in health care expenditures is a pay
cut for somebody in health care !!
????
Payors
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Pay for Performance
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Pay for Performance

• What Pay for Performance is NOT
• A increase in revenue
• A break-even with revenue
• What Pay for Performance IS
• A way to partially recoup some of the REDUCTIONS
  we will see in revenue

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Pay for Performance

• What Pay for Performance is NOT
• A increase in revenue
• A break-even with revenue
• What Pay for Performance IS
• A way to partially recoup some of the REDUCTIONS
  we will see in revenue

5 10 of Total Medicare Or more !!
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Hospital Acquired ConditionsCMS Approved
Effective October 1, 2008
Retained Foreign Body in Surgery
Air Embolus
ABO Blood Incompatability
 
Catheter Associated UTI
Central Line Associated BSI
Surgical Site Infection
 
Fractures, Falls, Injuries
Glycemic Control
Pressure Ulcers, Stages III and IV
DVT in hip and knee patients
Pay for Performance
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Reasonably PreventableAn Example from the Auto
Repair Shop
You take your car in to get the brakes
fixed. While fixing the brakes, the repairman
accidentally punctures the tire with the tire
iron. You now receive the following bill
Bill for Services Fixing Brakes
300 Repairing Tire 200
Total Due 500
Pay for Performance
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Real Life Example Value-Based Reimbursement Las
Palmas Medical Center 2011
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Core Measures-- Cost per Miss 2011 Performance
AMI 1 miss Loss in payout -- 47,116 Cost
47,116 per miss
Bottom Line Total at Risk 785,274 LEFT ON
TABLE 94,233
PN 6 misses Loss in payout --
39,263 Cost 7,852 per miss
HAI 3 misses Loss in payout --
7,853 Cost 2,618 per miss
HF 0 misses Loss in payout -- 0 Cost 0
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Core Measures-- Cost per Miss 2011 Performance
Double the amount at risk by 2017 !!!
AMI 1 miss Loss in payout -- 47,116 Cost
47,116 per miss
Bottom Line Total at Risk 785,274 LEFT ON
TABLE 94,233
PN 6 misses Loss in payout --
39,263 Cost 7,852 per miss
HAI 3 misses Loss in payout --
7,853 Cost 2,618 per miss
HF 0 misses Loss in payout -- 0 Cost 0
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Pay for Performance
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Physician Value Based Purchasing

• Include in the rule making process for 2013
• Based on quality compared to cost
• HHS is required to develop risk adjusted measures
• Applied for some physicians in 2015, all by 2017
• 1.5 payment reduction in 2015, 2 in 2016 and
  beyond

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The Lake Wobegon ParadoxPay for Performance

• Can all hospitals in the U.S. be in the top
  decile?
• Can we all be 5-stars?
• What do we do?

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Hospital Acquired Conditions

• Going from known complication..
• .. to known
  complication.

NO
Pay for Performance
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Surgical Consent Form.
Death Stroke Heart Attack Emergency
Surgery Infection Bleeding Allergic
Reaction Nerve Damage Renal Failure .
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Surgical Consent Form.. or Cop-Out
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• Perfection is unattainable. But if we chase it,
• we can catch excellence.
• Vince Lombardi

Change
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Questions for the Leadership Team

• Does your organization
• excel at pay for performance?

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Quality Challenges for a Ticket to the Game

• 1. Embrace Data Transparency
• 2. Promote Evidence-based practices
• 3. Prioritize Communication Skills
• 4. Add the Secret Sauce !!

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The Disconnect between Process and Outcome Whats
Missing ?
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The Disconnect between Process and Outcome Whats
Missing ?
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The Disconnect between Process and Outcome Whats
Missing ?
Whats Missing ??
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The Disconnect between Process and Outcome Whats
Missing ?
Patients are NOT Toyotas !
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The Disconnect between Process and Outcome Whats
Missing ?
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But, we are still not there.The Secret Sauce !!
Whats Missing ??
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But, we are still not there.The Secret Sauce !!
Whats Missing ??

• The Elucidation of the Obvious

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The Disconnect between Process and Outcome Whats
Missing ?
X
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The Disconnect between Process and Outcome Whats
Missing ?
The HUMAN Element !!
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The Secret SauceThe Human Element

• More than HCAHPS (although a great start !)
• more than touchy -- feelie
• beyond Information
  Technology fixes
• The Human Element

Communications Relationships Valuing the HUMAN
side of Medicine
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A Brief Digression.
1620- Somewhere in the Atlantic.
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Questions for the Leadership Team

• Does your organization
• value the Human side of medicine?

The HUMAN Element !!
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Quality Challenges for a Ticket to the Game

• 1. Embrace Data Transparency
• Implement Evidence-based practices
• Excel at Pay for Performance
• 4. Add the Secret Sauce !!

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Who Benefits?
The Patient !!
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Put it all Together
Are You Ready for the Game !!
Twelve Challenges for 2012
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Put it all Together
Are You Ready for the Game !!
We Still Have Time!!!
Twelve Challenges for 2012
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Are you Ready for the Game ?? Twelve challenges
for 2012

• Its the Cost, stupid !!
• Cost control will be more critical than ever
  before
• Any reduction in health care COST is a reduction
  in someones REVENUE
• Can you be cost-neutral with Medicare/ Medicaid
  within 3 years?

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Are you Ready for the Game ?? Twelve challenges
for 2012

• Define and Excel in your Core Business
• You cannot be all things to all people
• Critical services and service lines must be
  defined
• These must be prioritized on the basis of
  community need and operational feasibility
• VALUE has to be demonstrated for each service
  area with public data

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Are you Ready for the Game ?? Twelve challenges
for 2012

• Turn data into useful information
• The data is significant whether it is significant
  or not
• A lower rating usually points to a real problem
• Anticipate upcoming clinical measures and develop
  care improvement processes early
• Clinical data is driven by physician
  documentation
• A good doctor that does not document well is
  not a good doctor

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Are you Ready for the Game ?? Twelve challenges
for 2012

• Compliance with core measures is the Standard of
  Care
• 100 compliance is to be expected
• Variances are issues for peer review

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Are you Ready for the Game ?? Twelve challenges
for 2012

• Anticipate the continued growth of pay for
  performance
• Complications considered preventable will be not
  be reimbursed

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Are you Ready for the Game ?? Twelve challenges
for 2012

• Go from Known Complication to NO Complication
• View a hospital complication as industry views an
  industrial accident
• Set a goal/ benchmark of ZERO
• Never be too old a DOG to learn a new trick!!

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Are you Ready for the Game ?? Twelve challenges
for 2012

• Good information technology systems are essential
• Every system must develop and execute an IT
  strategy
• Successful systems must communicate
• Hospitals
• Physician to physician
• Ancilliaries
• Take full advantage of Incentives for
  Meaningful Use

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Are you Ready for the Game ?? Twelve challenges
for 2012

• Lose the I dont do cookbook medicine mentality
• Learn from the success of other industries
• Evidence-based clinical guidelines improve care
• Guidelines were never intended to apply to all
  patients

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Are you Ready for the Game ?? Twelve challenges
for 2012

• Theres no more room for individual players !!
• SYSTEM solutions trump INDIVIDUAL solutions
• Successful organizations need to learn to manage
  some risk

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Are you Ready for the Game ?? Twelve challenges
for 2012

• 10. Implement Best Practices in All Service
  Lines
• Best practices decrease adverse outcomes
• Avoid the temptation to tweak the guidelines

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Are you Ready for the Game ?? Twelve challenges
for 2012

• 11. Excel at Pay for Performance
• As much as 5-10 of all Medicare reimbursement
  can be at risk
• Successful performance in P4P may be the ONLY way
  to remain profitable in Medicare/ Medicaid

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Are you Ready for the Game ?? Twelve challenges
for 2012

• 12. Value the Human side of Medicine
• You ARE the Mayflower !!
• Demand SEAMLESS transitions of care
• Emphasize communication and relationships

The HUMAN Element !!
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• To the world you may be just one person,
• But to one person you may just be the world.
  Unknown

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