Now Viewing: Susan Dentzer: Toward a Healthy America

Carrots, Sticks, or Something Else? Motivating Doctors to Transform Health Care

Aug 14, 2013, 2:14 PM, Posted by Susan Dentzer

Craig Sammit Craig Sammit, MD, president and CEO of Dean Health System, and Holly Humphrey, MD, dean for Medical Education at the University of Chicago Pritzker School of Medicine

An old joke has it that the doctor’s pen is the costliest technology in medicine, since money typically flows where physicians’ prescriptions and other orders decide that it should go. As a result, influencing these decisions is key to achieving the Triple Aim of better health and health care at lower cost.

But what’s more likely to influence doctors: external factors, such as bonuses for improving the quality of care, or internal factors, such as appealing to their sense of altruism or satisfaction with their work?  In other words, carrots, sticks, or something altogether different—what Daniel H. Pink, author of Drive, calls “our innate human need to direct our own lives, to learn and create new things, and to do better by ourselves and our world”?

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The Latest Financial Scandal: Variations in Health Care

Jul 31, 2013, 9:54 AM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer

Imagine the outrage if an investigation uncovered a decades-old scheme in which hundreds of billions of taxpayer dollars were siphoned off to pay for health care of little to no value. That finding would probably mean that millions of Americans subjected to this unnecessary care could have been harmed as a result.

Guess what? An investigation—actually a new report from the Institute of Medicine—just did "uncover" such a scheme. And much of the original detective work was done by researchers at Dartmouth, supported in part through grants from the Robert Wood Johnson Foundation.

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Insurance Exchanges Foster Competition, Consumers Stand to Benefit

Jul 18, 2013, 12:52 PM, Posted by Susan Dentzer

Susan Dentzer
  • Health insurance for many individuals that is cheaper and better than what’s available now.
  • More competition among health insurers than ever before.
  • Partnerships between health plans and providers to deliver care at affordable cost.

These developments sound like the dreams of health reformers that fueled passage of the Affordable Care Act. But they’re proving to be reality now in many states—particularly in the 17 jurisdictions (including the District of Columbia) that are creating state-based health insurance exchanges, or “marketplaces.”

That’s the conclusion that emerges from analyses of the states participating in the Robert Wood Johnson Foundation’s State Reform Assistance Network. Housed at Princeton University’s Woodrow Wilson School, the program provides technical assistance to 11 states implementing coverage expansions under the health reform law.

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New Role for Health Care Providers: ‘Hot-Spotting’ Unhealthy Communities?

Jun 28, 2013, 9:21 AM, Posted by Susan Dentzer

In his now legendary approach to urban medicine, physician and Robert Wood Johnson Foundation grantee Jeffrey Brenner, MD, pioneered the technique of hot spotting—making block-by-block maps of Camden, N.J., examining residents’ hospital costs and identifying the handful of patients who cycled in and out of those institutions and racked up stratospheric medical bills.

What if America’s hospitals and health systems used similar techniques to identify the nation’s poorest and least healthy communities—and then teamed up with local community development organizations to set them on a path to better health?

David Fleming, a physician who directs Seattle’s public health department, made that pitch recently to members of the Foundation’s Commission to Build a Healthier America. National health reform, he said at the panel’s June 19 Washington meeting, affords an opportunity to nudge health care providers to reach outside their facilities to hot spot areas in need of health improvement. “The solutions to health in this country lie beyond the walls of the clinic and in our communities,” Fleming argued.

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Address Toxic Stress in Vulnerable Children and Families for a Healthier America

Jun 21, 2013, 1:43 PM, Posted by Susan Dentzer

Susan Dentzer

“Speed kills,” warns the traditional highway sign about the dangers of haste and traffic deaths. Now, we know that stress kills, too.

Toxic stress, at any rate. The human body’s response to normal amounts of stress—say, a bad day at the office—is likely to be brief increases in the heart rate and mild elevations in hormone levels. But a toxic stress response, stemming from exposure to a major shock or prolonged adversity such as physical or emotional abuse, can wreak far more havoc.         

In children, science now shows that toxic stress can disrupt the developing brain and organ systems. The accumulated lifelong toll of stress-related hormones sharply raises the risk of chronic diseases in adulthood, ranging from heart disease and diabetes to depression and atherosclerosis.

Thus, the message from a panel of experts to the Robert Wood Johnson Foundation’s Commission to Build a Healthier America was at once simple and challenging: Create a healthier environment for—and increase coping mechanisms and resilience in—the nation’s most vulnerable and stress-ridden children and families.

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Low-Cost, High-Quality Health Care: Not Made in the USA?

Jun 13, 2013, 3:22 PM, Posted by Susan Dentzer

Susan Dentzer

Imagine that you’re a heart patient. You go to the hospital for open heart surgery and recover successfully. As you leave for home, you’re handed a bill for the surgery and hospital stay—for $800.

In the high-priced world of U.S. health care, where charges for such procedures typically run into the six figures, that price is practically unthinkable. That’s why the idea of $800 heart surgery comes all the way from India—and why the largest nonprofit health and hospital system in the U.S.,  Ascension Health, wants to figure out how it might be replicated within its walls.

Americans are accustomed to thinking that the best ideas are hatched here and then exported abroad. But in health care, it’s clear that we have plenty to learn from other countries,  especially from efforts to provide care in low-resource settings, such as in much of Africa, Asia and Latin America. 

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U.S. Women: Many Missing From the Picture of Health

Jun 4, 2013, 4:21 PM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer

The missing women. The concept was first put forward by Nobel Prize-winning economist Amartya Sen in the 1980s. He pointed to demographic evidence that hundreds of millions of women were simply missing from the planet—most likely never having been born, or died, due to discrimination or neglect.

Biologically, females are stronger than males; as a result, in much of the world women outnumber men in population sex ratios. But Sen found the ratio was flipped in India, Pakistan, and Bangladesh. Subsequent investigations show a similar pattern in other parts of the world where women are at substantial economic and social disadvantage to men—including other countries in Asia, the Middle East, North Africa, and central and Eastern Europe.

Now, research sponsored in part by the Robert Wood Johnson Foundation raises the question: Is there a growing corps of “missing women” in the United States as well?

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To End Readmissions, Look to a Wired Community

May 30, 2013, 1:14 PM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer

What does it take to keep the sick and elderly from spinning through the revolving doors of the nation’s hospitals? Answer: A village.

Although avoiding unnecessary hospital readmissions is typically framed as an issue for hospitals, it’s more accurately seen as an issue for entire communities. One in five Medicare beneficiaries now end up back in the hospital within 30 days of discharge, at an estimated cost of more than $17 billion annually. It will take local health care communities working together to keep more of those patients at home, or at the very least, in a less acute care site.

A recent report from the Robert Wood Johnson Foundation, The Revolving Door: A Report on US Hospital Readmissions, profiles cases that make the point.

  • Eric was discharged from the hospital after being treated for chronic obstructive pulmonary disease, yet he didn’t fully understand how to use his inhaler and continued to smoke. He soon ended up back in the hospital. Whose responsibility was it to make sure that the cycle didn’t repeat itself? As it happened, his health plan eventually flagged him as at risk for readmission and he received regular follow-up care, such as smoking cessation classes, and having to answer five questions a day from his care team so they could monitor his breathing. 
  • Barbara, who has type 2 diabetes, was hospitalized with her blood sugar out of control, and then discharged without understanding how to administer her insulin properly or maintain an appropriate diet. Like Eric, she was one of the 50 percent of newly discharged Medicare patients who don’t see a primary care clinician or specialist within two weeks of leaving the hospital. Whose job was it to get her that appointment? It took a trip back to the hospital before she met with a dietitian and learned how to administer and adjust her insulin.

To crack down on avoidable readmissions, Medicare began penalizing hospitals last year if patients with three conditions—pneumonia, congestive heart failure, and heart attack—were readmitted within 30 days at rates above certain thresholds. At least two other federally sponsored efforts, the Partnership for Patients and the Community-Based Care Transition Program have also worked over the past several years to reduce avoidable readmission rates. A third, the Beacon Community Cooperative Agreement program, is now shedding a bright light on how communities can best use information technology in the process.

The Beacon program was part of 2009 federal legislation aimed at boosting adoption of electronic health records (EHRs) and other health information technology. Seventeen communities won three-year grants totaling  $250 million to use EHRs, and exchange of digital information among health care providers, to improve health and health care. Three of the communities—Cincinnati, Detroit and Western New York—are closely linked to the RWJF’s Aligning Forces for Quality efforts in those same communities.  

One tool that Beacon has tested is electronic alerts that originate in a hospital’s information system when patients undergo a change in status—for example, when they are admitted to the hospital, discharged, or transferred to another facility such as a nursing home. If the community has a health information exchange system, the message is processed and turned into an ADT alert, then sent to a primary care doctor or care manager. These professionals can then step in to smooth the transition and make certain that chronically ill patients get the attention they need.

Use of ADT alerts has been shown to deter unnecessary visits to the emergency room and initial as well as repeat hospitalizations. But communities must do a lot of hard work, together, to put them in place. They have to forge agreements with technology vendors, adopt data use agreements among providers, and undertake measures to protect patients’ privacy.  What’s more, primary care physicians usually have to adapt the way they practice medicine, becoming far more proactive rather than reactive.

Fortunately, even as the Beacon program draws to a close in September, the 17 communities have banded together as the “Beacon Nation” to share the lessons they’ve learned with others. The group recently released the first of eight learning guides, this one to help communities improve care transitions using the ADT alerts. (Full disclosure: Along with my foundation colleague Michael Painter, I serve as one of 14 unpaid members of an advisory committee to the Beacon Nation group.)

Following the steps in the learning guide isn’t simple, but the take-home message is, says Farzad Mostashari, head of the Office of the National Coordinator of Health Information Technology, which oversees the Beacon program. “What the guide teaches us is that it’s not all about the technology,” he says. “Incorporating the technology with the people [in the community]—that’s the lesson.”

In other words, welcome to today’s high-tech health care villages—where lots of dedicated people and communities are coming together to achieve the Triple Aim.

Sorting Out the Meaning of Hospital Pricing Disparities

May 21, 2013, 12:57 PM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer: Toward a Healthier America

What does U.S. health care have in common with an exotic international bazaar? The prices at either one are almost never posted, whether for a heart bypass operation or an antique rug. And the final price will almost certainly have little to do with the seller’s opening bid.

The nature of the U.S. medical bazaar was laid out earlier this month when the Centers for Medicare and Medicaid Services (CMS) released the prices billed to Medicare by more than 3,300 hospitals for 100 of the most common conditions or procedures. Not only was there wide variation in what hospitals charged, but there was also considerable variation in what Medicare actually paid—even though  hospital payment rates have been set prospectively, based on nearly 800 so-called diagnosis related groups (DRGs) for 30 years.

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Susan Dentzer: Toward a Healthy America

May 9, 2013, 4:38 PM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer

Many of the nation’s health economists are reviewing recent history to figure out what factors, besides the weak economy, might have caused health spending to slow over the past few years.  That’s a useful exercise, of course, but it’s even more crucial that we be hyper alert to the rocky health spending ahead—particularly as millions of Americans prepare to gain health coverage under the Affordable Care Act.

Towards that end, the Robert Wood Johnson Foundation recently teamed with several other nonprofits to fund four major analyses on health costs. The resulting reports, listed below, offer strategies for achieving a sustainable rate of growth of health spending, up to a trillion dollars’ worth of federal savings over a decade, and major improvements in the care provided to Americans.

In an era characterized by a lack of national consensus on so many pressing issues, these reports have a surprising amount in common. Each calls for even greater acceleration of the move away from fee-for-service payments to health providers, and toward payments pegged to improved health outcomes.  Almost all the reports propose major changes in Medicare and Medicaid, as well as extending payment and reforms to the privately reimbursed segments of the health care system.

Four reports do not a national groundswell make, but they could do provide the rationale for federal legislation, regulations and private sector system transformation that could further constrain health spending while improving care.

Medicare. Most of the reports envision fixing aspects of the traditional Medicare and Medicare Advantage programs, while simultaneously engaging in far broader reforms.

For example, the National Commission report proposes jettisoning Medicare’s troubled physician payment formula, asserting that it “has not worked in practice and shows no prospect of ever working.”  The Bipartisan Policy Center proposes replacing the formula with episode-based or case-based payments tied to quality measures, again breaking the longstanding link to fee-for-service, while The Partnership for Sustainable Health Care report calls for gearing Medicare payments for new treatments to their effectiveness relative to other treatment options already available.

As for the people those programs cover, both the Bending the Curve and Bipartisan Policy Center reports propose a new benefit structure for the traditional Medicare program that would better protect patients from catastrophic costs while imposing a combined $500 deductible for hospital and physician services.  Higher income Medicare beneficiaries would pay higher premiums. And to encourage more appropriate use of care, there would be no more “first-dollar” coverage available in Medigap supplemental insurance – only coverage with a deductible of at least $250, and a limit on covering no more than half of an enrollee’s Medicare copayments or coinsurance.

New Care Systems. More important, the reports recommend that all of Medicare transition to a dramatically new system of care provision and payment.  The Bipartisan Policy Center uses the terminology “Medicare Networks; Bending the Curve calls it “Medicare Comprehensive Care,” and says it would build heavily on emerging accountable care organizations. Providers would be paid capitated rates for assigned patients, and would have to meet a set of quality and performance measures to receive full payment.  These payments would grow over time no faster than the overall economy.   Within five years, Medicare beneficiaries could be encouraged to join these organizations through incentives, such as reductions in Medicare premiums and copayments.

Tax and Antitrust. The reports also agree on a need to cap the federal tax exclusion for employer-provided health insurance.  Taxing individuals on any employer contributions to fund the most expensive health would both raise revenue and curb some of the inducement for greater consumption of health care. What’s more, the reports argue that federal antitrust enforcement should block hospital consolidations that simply give the institutions greater power to raise prices, but encourage such mergers if it results in integrated delivery systems that take on financial risk for delivering inferior quality or excessive costs.

Medical Liability. This favorite issue of physicians is also addressed, with several of the reports recommending major changes in medical liability that would sway doctors away from providing excessive care meant to prevent lawsuits.  One recommendation is for so-called “safe harbor” protections for clinicians who effectively practice recognized standards of care, and call for replacing tort claims with a new system that would directly compensate injured patients.

Of course, if effectuating any of these changes were easy, it would already have happened. Enacting any of these proposals will run up hard against defenders of the status quo. But change begins with a groundswell of agreement around what is possible and desirable.  These reports provide an important starting point for the next round of serious health care reforms.