Filling the Disease Management Gaps in COPD

Vernon Pertelle

Reflect for a moment about the changes in healthcare over the past five years.  Now think about the transition from filling the inpatient beds and increasing overall volumes for surgical cases to reducing the length of stays and performing more procedures in same day centers or through robotics and minimally invasive methods. 

Then consider the methods and madness surrounding reimbursement for services and products under the Medicare Part B benefit; and the increased level of scrutiny and vigilance with utilization of resources relative to medical necessity.  No matter how you are affected, it is plain to see that things have definitely changed. Some may argue for the better because we are now charged with demonstrating value by improving health outcomes while reducing costs; while others may say things have changed too drastically and the patient will suffer as a result of the shift to value based healthcare.  

We have embarked on a new horizon in which health policy in our country is now focused on the patient. This is a very good thing because the system just might move away from a capitalistic and business centric model in which coverage has been the determining factor about using an effective resource; to one that will help improve healthcare in our country because using a resource that is effective - - is the right thing to do.  

The reality is that Centers for Medicare and Medicaid Services (CMS) has effectively gotten our attention to truly focus on establishing value for our patients; and will reward us for demonstrating better outcomes while reducing costs. 

We now must quantify data that clearly shows the use of resources results in better outcomes while reducing costs.¹ So, in the words of Michael Porter, management guru from Harvard Business School (HBS): "Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge."² So, the question then is how do we deal with the new normal in which we must demonstrate our value? 

Well, it begins with evaluating all of the resources in our armamentarium and critically assessing each intervention in terms of the value it adds to improving outcomes while reducing costs.  Take for instance patients that are diagnosed with Chronic Obstructive Pulmonary Disease (COPD); and the typical historic interventions and resources used to improve outcomes while reducing costs.  

Based on the evidence, we have done a poor job of effectively improving the outcomes of patients to the extent CMS has now included the diagnosis of COPD in the Hospital Readmission Reduction Program (HRRP) for FY 2015. We now must address the need to improve outcomes by considering tangible and effective alternatives that will help improve the overall care and outcomes.  The resource is a respiratory therapist (RT); specially trained, with laser sharp focus on the management of patients with COPD. The key is of course in developing programs and services that are centered on the patient with interventions that improve their engagement with self-management as well as adherence to their treatment plan.  

There are countless examples in regional and even some national managed care organizations on the effectiveness of this resource, yet - - by-and-large - - RT's have not been considered as essential in filling the disease management gaps. That said more must be done to demonstrate value and in essence establish RTs through validated clinical studies to once and for all get a better handle on the management of patients with COPD to improve health outcomes while reducing costs.

1 Michael E. Porter and Elizabeth Olmsted Teisberg, Redefining Health Care: Creating Value-Based Competition on Results (Boston: Harvard Business School Press, 2006), 86-87.

2 Michael E. Porter, “What Is Value in Health Care?” New England Journal of Medicine (2010) 363:2477-2481.

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The future of big data

Vernon Pertelle

Healthcare organizations and providers are charged with having the ability to quantify the data obtained from patients in the electronic health record (EHR) to show that the resources utilized in the care and treatment of patients results in better health outcomes while reducing costs.  

The expectations under the new healthcare laws and regulatory requirements; call for each entity whether hospitals and health systems or physicians to demonstrate meaningful use three (3) in which the data shows that the entity effectively cared for their patients.  So what does this mean for data analytics and dedicated resources with clinical and financial expertise to compile the information in a manner that is useful for the organization, relevant to Centers for Medicare and Medicaid Services (CMS) and allows for performance improvement?  

The future, current trends and direction of the New Healthcare Normal of pay for performance creates opportunities for information technology (IT) professionals that have expertise in clinical informatics and financial systems, budgeting and resource allocation. 

In order to effectively quantify your organization's performance in demonstrating meaningful use, establishing successful practices that lead to better health outcomes and cost reductions; as well as creating consistency with regards to connecting financial expenditures with clinical activities, each organization must create a new role that is focused solely on meaningful use demonstration.  

The individual is potentially a clinician with a passion for IT and formal education & training; and most important, understands the link between financial and clinical data.  This new role is one that may have existed in some organizations well in advance of the changes under the New Healthcare Normal; however will be essential for hospitals, health systems and physician practices to ensure the entity receives the rewards for performing better.  In addition, the role becomes a major component of the budgeting team to ensure resources are planned for and implemented at the right places, doing the right jobs, and for the right purposes.  The person is potentially a mid-level manager or director that reports in a matrix to the CFO, CNO; with regular interface with the CEO to ensure adequate authority and influence over the various teams and individuals accountable for performance.  

We have a plethora of data due to the systems and significant amount of information compiled via the EHR, financial systems, human resources and purchasing that can be leveraged to transform organizations into well run, efficient and quality driven entities. However there must be a dedicated resource that is accountable for quantifying the data in a manner that shows cost effective healthcare to demonstrate meaningful use.  The individual will help to shift the data paradigm to identify successful practices that can be shared throughout the organization and ultimately the healthcare industry.

The Patient's Experience with Care: Getting out of the box

Vernon Pertelle

We have heard countless clichés regarding the focus on the patient [which of course is intended to improve employee engagement with campaigns] to raise HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey scores.  The reality is that the vast majority of organizations rely on folks on the front lines to positively impact change, however the people who are in direct contact with the patients are typically overworked and stretched so thin that they tend to be task oriented versus patient centric.  The challenges with improving the patient’s perception of care stem from not having enough time to spend with each patient to make them feel like a person instead of an object.  The truth is that 'patient as customer' can sometimes be a burden on the healthcare worker when it comes to delivering exceptional person centered care.  

So, the question is how do we positively impact the patient's experience and most importantly how do we embed the processes and tactics into the culture of an organization? The answers vary based on the size and complexity of systems, workflows and whether or not best people is central to the organization.  However one prevailing fact is that people are people and if we start with the patient as person then that is a good beginning.  

The Arbinger Institute produced and wrote a book called "Leadership and Self Deception - Getting Out of the Box", in which the authors emphasized the need for everyone to be mindful of the roles they play in improving a situation or making it worse. The book provides life examples in a story on how various circumstances causes us to treat others as objects that help us accomplish our goals.

The authors have coined the term as "being in the box".  This of course is in contrast to viewing others as people, with hopes, dreams, desires and needs in which case the person is then considered to be "out of the box".  

It all sounds interesting right? It actually is and the book is very insightful and should be mandatory reading for an organization that is trying to shift the culture to one of accountability and patient centricity.  Put plainly, when a person is "in the box", they are essentially betraying themselves by not fulfilling their obligation to view each individual as a person.  Just imagine for a moment how you may have interacted with someone yesterday or today in which you were so focused on completing a task that your only concern was how the person [or object in this case] would contribute to you getting the job done.  This type of behavior limits our ability to excel, be fully engaged and mindful of the individual as a person. 

We often try to treat each individual as a person; but when we are deceived by the need to get the job done, and focused on our selfish needs; it forms the basis of self-deception.  This leads to blaming others, viewing ourselves as righteous, thus justifying our behavior.  In essence self-betrayal in practice causes self-deception.  When people question our behavior, we view them as enemies, however when they reinforce and agree with our behavior we view them as allies. 

When we apply these same concepts to patient care it is easy to understand why it is difficult to sustain the gains made from campaigns to improve the patient's perception of care. If we focus on the results alone then we are "in the box". When we are too busy with the task and our own results, versus the patient and what's best for the patient as a whole then we treat them as objects. 

The problem with being in the box is that it causes lack of commitment to each other and the team; conflict, stress, lack of trust, accountability and poor communication. The way we get out and stay out of the box is by having the servant mentality, being mindful of the needs of others and focused on the results of the organization and success of the team instead of ourselves.  So, now think for a moment, and ask yourselves the question:  How often am I "in the box" toward others?  As a leader, how often am I in the box towards my colleagues and subordinates? As a caregiver, how often am I in the box towards my patient? You'll be surprised by the answers.

In order to be effective with consistently improving the patient’s experience with care, the focus must be on the patient as person and must be a part of the culture.  Take a chance and read the book, then share it with others in your organization.  Then, suggest the book be a requirement of all new hires as well as existing staff, then have each person create three powerpoint slides in which first they describe their reaction when first asked to read the book; second, their perception after reading the book and third what they intend to do with the new knowledge.  Your patient’s will be the direct beneficiaries and your scores regarding their perceptions of care will improve.

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The KentuckyOne Case - Respiratory Therapist (RT) Value

Vernon Pertelle

When reviewing the article regarding the changes that were announced: KentuckyOne cuts respiratory therapists from emergency rooms; a few thoughts came to mind. First and foremost is the fact that the health system is a Market Based Organization (MBO) of Catholic Health Initiatives (CHI) of which, I was employed as the Vice President of Clinical Operations at another one of CHI's MBOs.  So I understand fully the period of discernment that occurs when making difficult decisions.  Second is the fact that respiratory therapists (RTs) are essential to meet the complex medical needs of patients with emergent and acute conditions of the lungs. Third, is that the perceived value relative to the actual benefits of the expertise RTs offer, was not clearly understood or articulated during the deliberations that concluded with the removal of respiratory therapists in the emergency rooms. 

The administrators of KentuckyOne made a decision that I'm sure they believed was in the best interest of Stewardship and possibly Growth; however may not have considered the potential negative impact on Quality and People. Each of the aforementioned [People, Quality, Stewardship and Growth] are core strategies of CHI and their MBOs.  Based on my understanding of those strategic pillars, having experienced them first hand (and selected as Top Talent in 2011 by demonstrating them); it is difficult to understand how respiratory therapists would be eliminated from the emergency rooms.  

The Centers for Medicare and Medicaid Services (CMS) has included Chronic Obstructive Pulmonary Disease (COPD) as one of the conditions that the Hospital Readmission Reduction Program (HRRP) will penalize hospitals for readmission. Respiratory therapists represent the single best resource to mitigate penalties for readmissions of patients with COPD.  The impact on Quality and frankly the patient's perceptions of care and their experience will be negative and ultimately will affect Growth, Stewardship and People. Nurses in the emergency room will be required to take on the role of respiratory therapist. The learning curve that the nursing staff will experience is difficult to quantify because it is possible (although not likely) that the nurses had begun a training program in anticipation of the change.  While nurses, based on their scope of practice are licensed to perform the procedures; their competence and skills may be lacking and as a result compromise health outcomes and lead to increased costs.  In FY 2014 the maximum penalties increased to 2% and in FY 2015 the maximum penalty will increase to 3% for the additional conditions including COPD.

Respiratory therapists add value to the goals of improving quality while reducing costs; which are central principles of the Affordable Care Act.  Eliminating the role of respiratory therapists in the emergency rooms may result in short-term savings for the health system, however the long-term repercussions on People, Quality, and Growth could be greater. Patients have choices about where they receive their care and they are more informed now, more than ever before, thus the changes will potentially impact the volumes of the health care system in outpatient settings, which is an area for Strategic Growth of CHI and their MBOs.  Maybe there needs to be reconsideration of the changes and rather than eliminate the role of respiratory therapists; expand the role in non-traditional areas such as Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs) and take advantage of the expertise respiratory therapists provide and create solutions to improve quality while reducing costs.

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Time for Change for the Better of the Patient

Vernon Pertelle

The New Healthcare Normal, requires organizations and health care workers to retrench and repackage in order to ensure survival in the era of the Affordable Care Act (ACA).  Market consolidation and new entrants are causing disruption in some areas, which is cause for concern for those that have not been proactive and have effectively prepared for change.

The healthcare industry in our country is relatively young, thus has experienced transitional evolution to where it should be focused - - - on the patient.  Too often we have been task oriented based on activities that generate revenue. Quality obviously has been a focus by most, but has not resulted in better health outcomes and reduced costs.  So, we are now charged with truly placing the patient at the center of everything we do on a daily basis.  It is interesting to note, that while we understand the needs of patients, it is much more enlightening when you or loved-ones are actually a patient; particularly if you are a healthcare worker.

The changes that are occurring may not be perfect for everyone but we have to start somewhere.  It is the fact that the costs overall are out of control and millions of Americans have lacked access to important care and services that could prevent serious illness and most important poor quality of life.  We frankly need to try to adjust in a way in which the patient and each citizen benefits from quality and affordable healthcare whenever they need it.  I was moved recently by a speech by president John F. Kennedy while visiting the presidential library in Boston, to learn that the prevailing issues of the day during the 60's included access to quality and affordable healthcare. So, if we consider the major events that have occurred in our nation, healthcare is right at the forefront of the need for change and improvement.

So let's for a moment reflect on the traditional healthcare models and how effective or frankly ineffective they have been to improve health and financial outcomes.  Overall we have struggled to improve in the very basic areas due to a clinical-financial disconnect.  While there has been significant evidence of certain interventions and clinical services to improve outcomes, little has been done to implement some of the services because of the lack of coverage or reimbursement.  Now we have an opportunity under Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs) to finally utilize services and solutions irrespective of whether or not they have been covered traditionally.  The key of course is to have the courage and innovative fortitude to integrate alternatives that will make an immediate impact on the improvements in health and financial outcomes.

The reality of change is here to stay and despite how you may feel about the politics or the policies, we absolutely must do something and rethink how we deliver healthcare in our country, so that the patient benefits from our efforts - - - for a change.