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John D. Bower School of Population Health

JDB LogoI’m honored to have been appointed as Graduate Faculty at the John D. Bower School of Population Health at the University of Mississippi Medical Center.

The School is one of the few schools of Population Health in the nation and “their mission is to educate leaders who will transform health care delivery and the health of Mississippians.

This really resonated with me as I had previously done work in Mississippi when Specialty Disease Management Services Inc. (SDM) was involved in the Medicaid disease management initiative as a subcontractor to McKesson Health Solutions.  SDM provided on the ground RNs and community care coordinators located throughout the state seeking to improve the health and care for Medicaid beneficiaries with asthma, diabetes heart failure and COPD. I also have in-laws in Leland, Mississippi in the heart of the Delta.

beech,-bettina1The school is led by Dr. Bettina Beech, their Dean, who is a dynamo building the school and truly working to embed the schools expertise into the state by getting involved in programs to leverage population health in an effort to improve the health of all Mississippians.  Her areas of scientific inquiry focus on the role of nutritional factors in the primary and secondary prevention of obesity and type 2 diabetes, with a particular focus on child health disparities.

The School has three departments, Data Science, Population Health Science and Preventive Medicine.  Offering an MS/PhD in Biostatistics and Data Science, an MS/PhD in Population Health Science and and their newly launched Executive MS in Population Health Management.

This semester I taught a course on ACO’s in their Executive Masters Program.

bower,-johnDiscussing the School of Population Health would be incomplete without mentioning John D. Bower, MD.  Dr. Bower was instrumental in establishing care for kidney dialysis and the federal legislation(H.R. 1) that made persons with end-stage renal disease eligible for Medicare. This was population health at its finest, embodying clinical practice,  healthcare system reform, program delivery and policy.  You can learn more about Dr. Bower and the work his foundation does here.

 

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PopHealth Week Interview with Dr. Anthony Slonim of Renown Health

This week’s episode of PopHealth Week had a broad ranging and fascinating interview with Anthony Slonim, MD the President and CEO of Renown Health. We cover their community efforts, ACO, the Healthy Nevada Genetic Testing initiative which already has 35,000 people enrolled, value based care and other topics.

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Listen to Anthony Slonim, MD on PopHealth Week

Dr. Slonim is an innovator and proven leader in healthcare at both the regional and downloadnational levels. During his notable career, Dr. Slonim has developed a profile as an expert in patient safety, accountable care, healthcare quality and innovative care delivery models focused on improving health within the community. He is board-certified in Internal Medicine, Pediatrics, Internal Medicine Critical Care and Pediatric Critical Care and is an academic leader with faculty appointments as Clinical Professor in the Departments of Internal Medicine and Pediatrics at the University of Nevada, Reno School of Medicine. He also holds a master’s degree and a doctorate in Administrative Medicine and Health Policy from George Washington University Center for Health Policy Studies and has more than 100 publications and 15 textbooks to his name.

Since joining Renown Health in July 2014, Dr. Slonim has reoriented northern Nevada’s largest locally governed, not-for-profit healthcare network. He launched a five-year strategic plan that is focused on the community’s overall health while embracing the national triple aim initiatives of improving quality care and patient satisfaction — all while reducing costs. Dr. Slonim also ushered in a new era of national collaboration to establish a medical training campus at Renown and expanded the region’s quaternary care services in collaboration with Stanford Medicine.”

http://www.blogtalkradio.com/pophealth-week/2018/09/26/meet-anthony-slonim-md-drph-fache-president-ceo-renownhealth

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The Triple Aim, Well Two Out of Three… Really is Bad

One of the Triple Aim‘s has gotten lost. Will anyone in the healthcare sector publicly declare that they are in fact working on the Double Aim?

The Triple Aim, that lofty set of goals that the healthcare system claims to have embraced:

  • Improving the patient experience of care (including quality and satisfaction);
  • Improving the health of populations; and.
  • Reducing the per capita cost of health care.

I agree with them and believe they are appropriate and necessary.

Everyone it seems, says they are working towards the Triple Aim, and many have taken to adding Provider Satisfaction and saying we in fact need a Quadruple Aim. Well, before we go there, let’s see what we are actually doing on the initial three.

After attending a number of conferences and seeing what the system is in fact doing,  I’m fairly certain, that healthcare is not actually going after the Triple Aim. In fact, it appears that almost everyone has quietly agreed on the “Double Aim” in an effort to short-circuit any true progress and continue on the path we have been on.

What do I mean by the Double Aim? Here are some examples of things I saw, heard or didn’t hear at HIMSS 2018:

After listening to an excellent panel on innovation, by three leading health system executives who oversee their systems innovation area or department, I just had to ask a question:

“At what point does this innovation actually lower costs?” A murmur arose in the room.

Response one:

“Well we could spend a whole day on that one”

The next answer? Well, there wasn’t one.

At the conclusion of the session, Gregg Masters spoke with one of the panelists and asked if as part of their innovation center they were tasked with lowering costs.  Their response “no, that’s not part of our charge.”

Why wouldn’t an innovation center also be looking for innovation that reduces costs?

At a dinner panel one evening, a health plan association executive when asked if health plans were really lowering costs, pointed to the Medical Loss Ratio (MLR) Rule (which I have written about here) as a key contributor to holding costs down.  When I explained my belief that the MLR rule ensures costs go up because “who would want 15% of a lower number next year” there were audible chuckles of agreement in the room, a shocked look on the panelists face and the panel quickly switched to another topic. While the person who asked the original cost question, looked at me, raised his eyebrows and laughed.

I do not recall any booth or individual discussing programs that save money, in fact most were talking about revenue enhancement.

Only Kaveh Safavi of Accenture and one other presentation discussed the elephant in the room; that healthcare is the only industry where as it adds technology, the workforce gets less efficient.  I would call the behavior we exhibit in this regard, an addiction.  We continue to do it, even though the outcomes will be bad for us.

Do we not hear the clamor associated with the Amazon, Berkshire-Hathaway, JP Morgan?

“Healthcare is the Tapeworm of the American economy”

 

Or the announcement by Wal-Mart regarding their narrow network, in which they said that about 40% of people referred to their center of excellence for back surgery were told they don’t need it. How about the growing relevance of Dave Chase and the Health Rosetta and books like Dan Munro’s Casino Healthcare, or the Health Value Awards.

Even the esteemed Dr. David Nash of the Jefferson College of Population Health saying there are too many medical errors and too many tests being ordered and it was “time for doctors to look in the mirror”.  But not just doctors, all sectors of healthcare, especially hospital systems, health plans, device and pharmaceutical manufacturers and vendors. You may be thinking you can slip by with the Double Aim, but others are AIMing to knock the inappropriate costs out of the system, and if you don’t get involved it might be you.

And now when CMS announces their Pathways to Success, a new ACO requirement that pushes ACOs which have been living off of one-sided risk in the MSSP program, and showing no savings, to two-sided risk, the industry goes bonkers.

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We know there are excesses in the system, everyone talks about that, everyone talks about the Triple Aim, but it seems in the case of doing things versus talking about the Triple Aim, we are truly only interested in the Double Aim.

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Webinar on SDoH and Geospatial Data

I recently the pleasure of participating in a Webinar with Joe Warbington of Qlik moderated by Mike Perkowski on

Visualizing population health: How geospatial and social determinant data informs preventive care

 

You can watch it here..

 

 

 

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Population Health and the End of Life

“Health nuts are going to feel stupid someday, lying in hospitals dying of nothing.”
Red Foxx
 Dad and Fred
In population health we talk a lot about improving the health of those with chronic diseases, preventing other diseases and keeping the healthy people healthy, but what should population health’s role be at the end of life? In the end, even if we are wildly successful at maintaining, improving or preventing diseases and conditions, we will still face death.
If the Triple Aim is better outcomes, lower costs, and improved health of populations, how should that be applied at the end of life? I believe its role should be in ensuring dignity, education and appropriate personal decision-making.
Over three years ago my father, a physician passed away.  He had been living with Lewy Body Dementia, a form of Parkinson’s disease for almost two decades.  When first diagnosed, he made clear to us how his disease would progress and what he wanted to happen at the end.   No feeding tubes, no extraordinary measures, if he got pneumonia, he wanted no antibiotics. When his disease had really progressed and he was bed ridden in a memory care unit, post stroke and not always lucid, he did get that infection. The facility wanted him transferred to the hospital across the street where he would get treated for his pneumonia.  While they were  nervous about us not approving that based upon his Advanced Directives, they understood his wishes, worked with us and hospice and we made clear that we would not hold them in any way accountable.
The hospice service was fantastic as was the facility which allowed my mother and others to stay there with him.  During this three weeks, we would take him outside when he was able and we were there with him throughout.  It was a moving and gentle experience and I am happy to have spent that time with him, my family and some of his friends and colleagues. During this experience, not everyone in the immediate family was in agreement, or felt it was handled as they wanted, but they knew it was being done based on his clear wishes.
We all know the costs associated with healthcare at the end of life, but that is a secondary issue; it’s hard to say goodbye to someone you love. Knowing his disease and its course, we were able to prepare for a long time. Others have much less time to make decisions and say what they feel is an appropriate goodbye. This is why we should think of the how and what we want to happen for us early, and clearly discuss it with our loved ones.
Too often when the end of life is near, it’s not about the person reaching that end, but about those close to her or him, about their time with the person, perhaps their guilt, the belief that they need to do everything possible. While this may seem like the right thing to do, many times it just increases the pain and suffering of the person nearing the end of their life. In a number of instances, I have seen and discussed the guilt felt by those who had gone to great lengths to try to keep their loved one from death.  The hospitalizations, intubations, amputations, feeding tubes, more doses of chemo. Hindsight is 20/20 for better or worse.
In fact, one of the things that influenced my father and his decision, was the death of his father. He had really suffered during the last 6 months as the doctors did this and that to (for?) him in an effort to try to keep him alive.  My father had supported some of these efforts. They were not a good six months, certainly not six months worth living; in fact my grandfather on at least one occasion had stated that he was ready to die. But more was done. Back then there was little talk of options or hospice.  My father sometimes spoke of his father’s last 6 months, at times with a tinge of guilt.
With advanced directives, we have come a long way, but there is still more we need to do.
If population health is about the full continuum of care with the patient at the center, we have to ensure that end of life decisions becomes part of the discussion. That people and their loved ones are educated about their options, given an opportunity to prepare for the day, and given the support to make the decision’s as they see fit. For my Father and us, his decisions made a world of difference and the hospice and memory care unit did an incredible job taking us through this difficult time. He died and left us in peace with memories of a great man, who was loved deeply by his family and still is.
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