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Collaborating in Pennsylvania to promote healthcare transparency, delivery system redesign, and payment reform

In the second discussion in our “Ask the Experts” series, Dr. Dennis Scanlon speaks with Keith Kanel, MD, Chief Medical Officer of the Pittsburgh Regional Health Initiative (PRHI), to understand the landscape and relationships among healthcare transparency, delivery system redesign, and payment reform.

Interview Highlights

The Pittsburgh Regional Health Initiative (PRHI)

“[PRHI is] A regional health improvement collaborative founded by the business community and regional hospitals. They were looking for a neutral convener that could help establish a roundtable for innovation that occurred in this region. Our portfolio of work right now extends from readmission reduction projects to integrating behavioral health in primary care settings. We work in long-term care—we are very deeply involved in primary care transformation. We try to work on the gamut of health care problems that might be relevant to western Pennsylvania.”

How to collaborate in a competitive industry

“We really try to strike noble goals. We find that most people, even in the most competitive settings, really enjoy collaborating when they can. We are so much stronger when we work together. In our health systems and in our health plans we are incredibility successful in getting them to work together when we try to maintain a fair, even process.”

Healthcare safety and quality improvement

“One of our original founders was Paul O’Neill. He was at Alcoa and he had just turned Alcoa from a dangerous workplace to one of the safest companies in the world by using Lean Toyota Principles and also establishing very high levels of accountability on the part of his managers. We’ve taken those methods and tried to apply them to the hospital setting. To date, we have trained well over 5,000 people around the world in those Lean methods.”

“Currently, it is felt that about 40% of what we do in health care is waste: unnecessary repeated x-rays, repeated blood tests, repeated readmissions to the hospital. If you can find strategies to reduce those low value or no value parts of health care, you are well on your way to a better system.”

The importance of healthcare transparency and reaching the activated and connected patient

“We cannot advocate transparency enough. It is bringing consumers into health care which is long overdue. We are seeing a new generation of consumers that we are calling the ‘activated patient’—the patient that wants to be involved in their selection of healthcare services an offshoot of the ‘activated patient’ is something called the ‘connected patient’ that wants to access healthcare information on the internet information that they want when they want it. They are applying the same principles they would use if they were buying a car or planning a vacation.”

Healthcare transparency tools for consumers

“We are seeing right now the advancement of a few transparency tools. The first tool is public reporting issuing report cards on physicians, medical groups, and hospitals that are done typically by state agencies and typically focus on quality measures the Federal Government has been doing this for over a decade a lot of this information has been in the public domain for a long time. However, it is woefully underused. We are also seeing all-payer claims databases that can create report cards of care in the state and make them available to consumers. Eighteen states have all-payer claims databases. One thing we are seeing is that consumers are saying the information is there but it is not actionable consumers are looking for much more customized transparency tools.”

“I think consumers are looking for simplicity. Health care is so intimidating and so complex that they do want something that they can understand. We need consumers to be much more engaged, a campaign where we can inform them how to use some of these transparency tools.”

Successes and failures of healthcare transparency

“Most of these [transparency] tools have only been in the field for 5 or 10 years so we don’t have a lot of experience with them just to share one, we are working with some colleagues in Wisconsin where they put public report cards out on certain primary care physicians. What they found are that those physicians over time improved their performance on quality measures. So transparency, or the shining of a spotlight on suboptimal care, does cause it to improve.”

“Does sharing prices help people make better buying decisions? California has had their charge master online for many years and there is no evidence that people make wiser decisions based on publicly available prices. Something that is very interesting is this notion that public reporting can actually increase spending on health care. Believe it or not, when people are given menus of prices for health care, they don’t rush to pursue the lowest cost care there is concern of patients mistakenly assuming that higher prices mean higher quality, may pursue more expensive health care.”

Healthcare transparency in Pennsylvania

“Pennsylvania has a long and storied history in transparency. There is an organization in the state called the Pennsylvania Healthcare Cost Containment Council, we call it PHC4 for short. Far too few people know about the fabulous work done by this database. This is actually one of the oldest and largest centrally collected data sets in the country. The state legislature in 1986 said that all hospitals had to submit structured data to a central authority every year on the performance of its hospitals. We know enormous amounts about readmission rates, about hospital acquired infections, about heart surgeries and orthopedic surgeries PHC4 has created a series of buying guides for consumers.”

“There is a group called the Catalyst for Payment Reform (CPR) that has gone around the country and has done a report card on each state’s reporting system. Despite PHC4 being the pride of our Commonwealth, we got an “F” from CPR on the report card when it came to transparency effort. We weren’t alone, there were actually 45 states out of 50 that got an “F” from CPR. We are looking at the [states] that did much better and what they were doing is they had all-payer claims databases with really robust data available on fabulous websites.”

“We know where we want to go as a state. There are about 200 individuals in Harrisburg working on making health care better in the Commonwealth I think this is going to be a very lively year when it comes to transparency and payment reform happening in our state.”

Delivery System Redesign in Pennsylvania

“At PRHI we are promoting a concept called the Primary Care Resource Center (PCRC) concept. We are working with community hospitals finding out why they don’t participate in ACOs [Accountable Care Organizations], why they don’t participate in bundled payments. What we found is they just don’t have the scale and the quality improvement resources to do this. So in our PCRC project, which we have been promoting in seven health systems around the commonwealth, what we are doing is creating hubs that help with care transitions from the hospital to the community, and support primary care practices which don’t have the resources to meet the needs of their populations this is just one idea that we think can dovetail with other federal ideas to really change the face of Pennsylvania health care.”

The role of social determinants of health and health system reform in PA

“Most health care does not occur in hospitals and doctors’ offices. It occurs in communities. We have been convening meetings in western Pennsylvania for all the agencies from Meals on Wheels to free clinics to FQHCs [Federally Qualified Health Centers] to United Way. We have been bringing them together around one table to talk about how we can create something like [an accountable health community]. One of the things we are really trying to work on is building that connection.”

“We are just starting to do some work with the state of Pennsylvania at promoting community health workers in our region. But the problem is there is no payment mechanism either through Medicare, through Medicaid, or through the commercial payers that can make these services happen. What our goal at PRHI is to leverage funding to make this happen if nothing more as a demonstration. Then once we show the value, then reach out and try to make it part of everyday health care. We’ve had incredible success with the Commonwealth of Pennsylvania. The Department of Human Services has been completely engaged with us in making this happen.”