A Proposed Shared Vision for Leadership Development for all Medical Students: A Call from a Coalition of Diverse Medical Schools.

Issue: Despite clear relevance, need, descriptive literature, and student interest, few schools offer required curriculum to develop leadership skills. This paper outlines a proposed shared vision for leadership development drawn from a coalition of diverse medical schools. We advocate that leadership development is about self (looking inward), teams (not hierarchy), and change (looking outward). We propose that leadership development is for all medical students, not for a subset, and we believe that leadership curricula and programs must be experiential and applied. Evidence: This paper also draws on the current literature and the experience of medical schools participating in the American Medical Association's (AMA) Accelerating Change in Medical Education Consortium, confronts the common arguments against leadership training in medical education, and provides three cross-cutting principles that we believe must each be incorporated in all medical student-centered leadership development programs as they emerge and evolve at medical schools. Implications: By confronting common arguments against leadership training and providing a framework for such training, we give medical educators important tools and insights into developing leadership training for all students at their institutions.

Patient attribution: why the method matters.

OBJECTIVES: To assess the impact of 5 commonly used patient attribution methods on measured healthcare cost, quality, and utilization metrics within an integrated healthcare delivery system. STUDY DESIGN: Cross-sectional analysis of administrative data of all patients attributed (by any of 5 methods) and/or paneled to a primary care provider (PCP) at Mayo Clinic Rochester (MCR) in 2011. METHODS: We retrospectively applied 5 attribution methods to MCR administrative data from January 1, 2010, to December 31, 2011. MCR is an integrated healthcare delivery system serving primary care and referral populations. The referral practice is geographically colocated but otherwise distinct from 6 primary care practice sites that include pediatric, internal medicine, and family medicine groups. Patients attributed by each method were compared on their concordance with PCP empanelment, quality measures, healthcare utilization, and total costs of care. RESULTS: The 5 methods attributed between 61,813 (42%) and 106,152 (72%) of paneled patients to a PCP at MCR, although not necessarily to the paneled PCP. There was marked variation in care utilization and total costs of care, but not quality measures, among patients attributed by the different methods and between those paneled versus not paneled. Patients with more primary care visits were more likely to be attributed by all methods. CONCLUSIONS: Reliable identification of the physician-patient relationship is necessary for accurate evaluation of healthcare processes, efficiencies, and outcomes. Optimization and standardization of attribution methods are therefore essential as health systems, payers, and policy makers seek to evaluate and improve the value of delivered care.

Looking Under the Streetlight? A Framework for Differentiating Performance Measures by Level of Care in a Value-Based Payment Environment.

The majority of quality measures used to assess providers and hospitals are based on easily obtained data, focused on a few dimensions of quality, and developed mainly for primary/community care and population health. While this approach supports efforts focused on addressing the triple aim of health care, many current quality report cards and assessments do not reflect the breadth or complexity of many referral center practices.In this article, the authors highlight the differences between population health efforts and referral care and address issues related to value measurement and performance assessment. They discuss why measures may need to differ across the three levels of care (primary/community care, secondary care, complex care) and illustrate the need for further risk adjustment to eliminate referral bias.With continued movement toward value-based purchasing, performance measures and reimbursement schemes need to reflect the increased level of intensity required to provide complex care. The authors propose a framework to operationalize value measurement and payment for specialty care, and they make specific recommendations to improve performance measurement for complex patients. Implementing such a framework to differentiate performance measures by level of care involves coordinated efforts to change both policy and operational platforms. An essential component of this framework is a new model that defines the characteristics of patients who require complex care and standardizes metrics that incorporate those definitions.

The High Value Healthcare Collaborative: Observational Analyses of Care Episodes for Hip and Knee Arthroplasty Surgery.

BACKGROUND: Broader use of value-based reimbursement models will require providers to transparently demonstrate health care value. We sought to determine and report cost and quality data for episodes of hip and knee arthroplasty surgery among 13 members of the High Value Healthcare Collaborative (HVHC), a consortium of health care systems interested in improving health care value. METHODS: We conducted a retrospective, cross-sectional observational cohort study of 30-day episodes of care for hip and knee arthroplasty in fee-for-service Medicare beneficiaries aged 65 or older who had hip or knee osteoarthritis and used 1 of 13 HVHC member systems for uncomplicated primary hip arthroplasty (N = 8853) or knee arthroplasty (N = 16,434), respectively, in 2012 or 2013. At the system level, we calculated: per-capita utilization rates; postoperative complication rates; standardized total, acute, and postacute care Medicare expenditures for 30-day episodes of care; and the modeled impact of reducing episode expenditures or per-capita utilization rates. RESULTS: Adjusted per-capita utilization rates varied across HVHC systems and postacute care reimbursements varied more than 3-fold for both types of arthroplasty in both years. Regression analysis confirmed that total episode and postacute care reimbursements significantly differed across HVHC members after considering patient demographic differences. Potential Medicare cost savings were greatest for knee arthroplasty surgery and when lower total reimbursement targets were achieved. CONCLUSION: The substantial variation that we found offers opportunities for learning and collaboration to collectively improve outcomes, reduce costs, and enhance value. Ceteris paribus, reducing per-episode reimbursements would achieve greater Medicare cost savings than reducing per-capita rates.

Physician leadership in changing times.

Today, hospitals and physicians are reorganizing themselves in novel ways to take advantage of payment incentives that reward shared accountability for the total health care experience. These delivery system changes will take place with our without physician leadership. To optimize change on behalf of patients, physicians must play a conscious role in shaping future health care delivery organizations. As physician leaders of three of the nation׳s largest integrated health care delivery systems - Kaiser Permanente, Virginia Mason Medical Center, and the Mayo Clinic Health System - we call on physicians to view leadership and the development of leaders as key aspects of their role as patient advocates.

Episode-based payment: evaluating the impact on chronic conditions.

BACKGROUND: Policy makers are interested in aggregating fee-for-service reimbursement into episode-based bundle payments, hoping it will lead to greater efficiency in the provision of care. The focus of bundled payment initiatives has been upon surgical or discrete procedures. Relatively little is known about calculating and implementing episode-based payments for chronic conditions. OBJECTIVE: Compare the differences in two different episode-creation algorithms for two common chronic conditions: diabetes and coronary artery disease (CAD). STUDY DESIGN: We conducted a retrospective evaluation using enrollees with continuous coverage in a self-funded plan from 2003 to 2006, meeting Healthcare Effectiveness Data and Information Set (HEDIS) criteria for diabetes or CAD. For each condition, an annual episode-based payment was assessed using two algorithms: Episode Treatment Groups (ETGs) and the Prometheus model. PRINCIPAL FINDINGS: We began with 1,580 diabetes patients with a 4-year total payment mean of $67,280. ETGs identified 1,447 (92%) as having diabetes with 4-year episode-based mean payments of $12,731; while the Prometheus model identified 1,512 (96%) as having diabetes, but included only 1,195 of them in the Prometheus model with mean diabetes payments of $23,250. Beginning with 1,644 CAD patients with a 4-year total payment mean of $65,661, ETGs identified 983 patients (60%) with a 4-year episode-based mean of $24,362. The Prometheus model identified 1,135 (69%) as CAD patients with 948 CAD patients having a mean of $26,536. CONCLUSIONS: The two episode-based methods identify different patients with these two chronic conditions. In addition, there are significant differences in the episode-based payment estimates for diabetes, but similar estimates for CAD. Implementing episode-based payments for chronic conditions is challenging, and thoughtful discussions are needed to determine appropriate payments.

Mayo Clinic employees responded to new requirements for cost sharing by reducing possibly unneeded health services use.

Some health plans have experimented with increasing consumer cost sharing, on the theory that consumers will use less unnecessary health care if they are expected to bear some of the financial responsibility for it. However, it is unclear whether the resulting decrease in use is sustained beyond one or two years. In 2004 Mayo Clinic's self-funded health plan increased cost sharing for its employees and their dependents for specialty care visits (adding a $25 copayment to the high-premium option) and other services such as imaging, testing, and outpatient procedures (adding 10 or 20 percent coinsurance, depending on the option). The plan also removed all cost sharing for visits to primary care providers and for preventive services such as colorectal screening and mammography. The result was large decreases in the use of diagnostic testing and outpatient procedures that were sustained for four years, and an immediate decrease in the use of imaging that later rebounded (possibly to levels below the expected trend). Beneficiaries decreased visits to specialists but did not make greater use of primary care services. These results suggest that implementing relatively low levels of cost sharing can lead to a long-term decrease in utilization.

Effect of multiple chronic conditions among working-age adults.

OBJECTIVE: To determine the longitudinal effect on healthcare costs of multiple chronic conditions among adults aged 18 to 64 years. STUDY DESIGN: Retrospective cohort assessment of working-age employees and their dependents with continuous coverage in a self-funded health plan from January 1, 2004, to December 31, 2007. Data were obtained from health benefit enrollment files and from medical and pharmacy claims. METHODS: Individuals were defined as having chronic conditions based on modification of a published method. The mean annual healthcare costs were estimated for individuals with 0, 1, 2, 3, 4, or 5 or more chronic conditions. The probability of persistence in high-cost categories across years was estimated for individuals in each group. RESULTS: Overall, 75.3% of working-age adult enrollees had at least 1 chronic condition, 54.3% had multiple chronic conditions, and 16.5% had 5 or more chronic conditions. The cost of healthcare was higher among individuals with more chronic conditions for all ages. The mean medical cost per year for an individual with no chronic conditions was $2137, while that for an individual with 5 or more chronic conditions was $21,183. Enrollees with more chronic conditions had higher persistence in high-cost categories between years and persisted at these high costs for more years. CONCLUSIONS: While multiple chronic conditions are common in the population 65 years and older, they are also of great concern for the working-age population. Understanding how to effectively manage individuals with multiple chronic conditions is an important challenge. Effective care management focused on managing the patient as opposed to a condition has the potential to significantly affect healthcare costs.

Creating value in depression management.

BACKGROUND: in the current healthcare system in the USA, common mental health conditions are frequently undertreated. As a result, unacceptable disability, morbidity and mortality rates occur. Various stakeholders define, provide, monitor and may reward providers of mental health care, but based on differing interests and agendas. Examples of the implementation of evidence-based practice in general care, accompanied by changes in fiscal incentives, are rare outside of research endeavours. METHODS: we review as a case study a Minnesota state-wide effort to introduce collaborative care into 80 primary care clinics in order to improve the outcomes of depressed patients. This effort has been named the DIAMOND project (Depression Initiative Across Minnesota, Offering a New Direction) and it may illustrate several key steps towards creating value at the interface between primary care and specialty mental health care. Outcomes were defined and will be examined for a three-year period from when the initiative began in March 2008. RESULTS: to date the results are encouraging. All 80 clinics have introduced a new measurement tool into their practices, trained and hired care managers, and have developed an ongoing relationship with a psychiatrist. Over 4800 patients have been screened for depression, have received treatment and have been followed to ensure compliance and better outcomes. Remission rates (averaging 27%) are at levels comparable to research studies which have more stringent inclusion and exclusion criteria. Challenges including the loss of eligible patients are described. CONCLUSION: to create value in depression management, not only was a viable model required, but also a process for implementation and a structure for ongoing support of the model. The case study presented offers lessons that might be applied elsewhere toward creating value at the mental health and primary care interface.

Framing change for high-value healthcare systems.

Healthcare providers are challenged by forces that are driving change at an accelerated rate. Unfortunately, organizational structures, system inertia, and the lack of shared values in many organizations thwart change. Systems that do not understand the principles of change management for complex adaptive systems (CAS) continue to apply change models that have little chance of success. An understanding of the principles and actions that enable change in CAS and the use of a formal process to frame and focus change are essential for long-term success.