• Health-Care Reform, Corporate-Style - Toyota and others are opening onsite medical centers. It's possible that employers in this situation are most able to have a societal perspective.

Shai, Iris, Dan Schwarzfuchs, Yaakov Henkin, Danit R. Shahar, Shula Witkow, Ilana Greenberg, et al. “Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet.” N Engl J Med 359, no. 3 (July 17, 2008): 229-241.

“The Employer as Health Coach,” October 11, 2007.

I initially reviewed this article for my interest in the question, “What kind of diet is best for losing weight?” (with good news for low carbohydrate and Mediterranean dieters), but I quickly became fascinated with the way this study was performed - on the worksite, at the Nuclear Research Center Negev, in Dimona Israel.

To quote:

As Okie recently suggested, using the employer as a health coach could be a cost-effective way to improve health. The model of intervention with the use of dietary group sessions, spousal support, food labels, and monthly weighing in the workplace within the framework of a health promotion campaign might yield weight reduction and long-term health benefits.

I think this is as significant as the weight loss intervention itself - that the study authors worked to modify the work environment to support the study aims. In the supplemental materials (linked here), you can see an example of the signage placed in the cafeteria to alert employees to the different food choices available, depending on which arm of the study they were in.

I think this fact of the study design is under-emphasized and marks an important trend in supporting interventions like this moving forward. With thanks to the Research Center in Dimona for teaching the world about more than nuclear science.

(presentations online here)

Paul Grundy, MD - “Think huge”

Purchaser guide - there have been many of these, but the first time one prepared with consumers and providers

Health Information Technology - help educate, advocate, demonstrate around PCMH the technology that will be necessary to help physicians make the transformation

Panel - What Does it Cost to Become a Patient Centered Medical Home?

Bob Berenson, MD, Senior Fellow, The Urban Institute

“A good medical home”- patient with superficial phlebitis treated via one office visit, 6 phone calls, 6 e-mails, including hematologic consultation, one reimbursement for in-office care

Julia Pillsbury, DO, Alternate RUC Representative, American Academy of Pediatrics

New G codes for Medical Home-type work. Crosswalked to currently existing codes, some subsume current G codes, some do not. Tier 1, 2, and 3, between 6.5 to 9.2 minutes per patient per month, may be around $50/member/month.

Patient Partnership

Sabrina Corlette, Director of Health Policy, The National Partnership for Women and Families

Grant from the Wellpoint Foundation to introduce consumer advocates to PCMH and involve them and shaping it. Environmental scan, Focus Groups, Develop consumer/patient principles

Debbie Peikes, Ph.D., Mathematica Policy Research

We should involve patients and providers in primary care assignment, using claims retrospectively is expedient perhaps but has difficulties

As the title says, my Internet holiday is complete. It was as fun as being in the cloud, to be sure. I’ll be back to regular publishing now, and comments and pings are turned back on.

Patient Centered Primary Care Collaborative, Washington, DC

I’m resuming life in the cloud by attending the Patient Centered Primary Care Collaborative Stakeholders Working Meeting, here in Washington, DC. I hope to post updates throughout the day - we are all fortunate that this group operates with an impressive level of openness and interest in collaboration (just as its name implies). The agenda and materials are online for others to peruse.

By the way, here’s what an Internet Holiday looks like.

A3 (Project Plan). Click here to learn more about what an A3 is

This post contains the A3 Document, or the Project Plan, for Connectivity for California Consumers. I have been posting some of the data that supports this plan on this blog (click here to see them all). In addition, I have been working with staff at California Healthcare Foundation and potential stakeholders to improve the plan.

For those of you unfamiliar with the A3 format, it is designed to (a) tell a story and (b) incrementally improved to the point that the actions are clear at the time a project is launched. It may be revised once a day or even more often. The process of discussing the project and making improvements is called “nemawashi.” I am using this blog for extended nemawashi, so please post your comments.

Since an A3 tells a story, starting on the left, going down, and then on the right, I will summarize the story here. Feel free to print out the A3 and follow along (A3 means “11 x 17″ paper. You may have to shrink to fit on letter size).

Issue & Focus

1. The California Healthcare Foundation is dedicated to the improvement of the lives of Californians managing chronic illnesses.
2. There are many community stakeholders involved in supporting this goal; their work could be improved by making connections to each other that are meaningful for patients.
3. This is part of a broader strategic plan to support the objective of involving patients and families in all aspects of their care. This is the identified gap to be closed through this work.
4. California Healthcare Foundation is seen as catalyst and partner for patient engagement in California

Current Condition

1. There are well known gaps the care of people with high blood pressure
2. The impact of these gaps is distributed across stakeholders differently compared to other chronic illnesses, which includes a strong productivity-loss component, due to the high prevalence of the condition in employed populations (see charts).
3. There are examples of employers and technology companies approaching these gaps in hypertension and other chronic illnesses that can be studied.

Problem Analysis

1. Lack of access to care accounts for only 10% of poor blood pressure control; there is a physician component in setting goals, and a patient component in operationalizing those goals, that may not be accomplished in physician visits alone.
2. Patients who are not seen at least every 12 months are at greater risk for non-adherence
3. The societal costs of inadequate management are spread diffusely; few organizations are able to to see the total harm from this perspective
4. There are few models outside of integrated care systems of using non-visit-based approaches to managing chronic illness.
5. We are just entering an era of interoperability, with many solutions not yet integrated into the value chain of patients and payers

Target Condition

This pilot seeks to create a functioning ecosystem that supports chronic disease management across the lifecycle, with the best candidate being hypertension

Action Plan

We began by interviewing example employers, health care providers, and technology providers to understand which approaches and components appeared most promising. At this time, it seems most reasonable to approach this first from the employer perspective.

Next step will be to convene a group of potential partners in June or July, 2008, at California Healthcare Foundation, to discuss how pieces would fit together.

A presentation would be made to the CHCF Board in the fall, with funding and activity to begin in 2009.

Cost / Cost-Benefit / Waste Recognition

There are recognized wastes, which include unnecessary visits for blood pressure monitoring, inadequate medication therapy, and inadequate use of the health system, for patients who have not been seen in the past 12 months.

There are costs including, technology costs (although the goal is not to build anything new), and realignment of incentives to support non-visit-based care.

Followup / Unresolved Issues

Points of concern and planned countermeasures

1. What is the metric for patient access? (Pacific Business Group on Health is working on an employee engagement survey; metrics for patient access to their health data may need to be developed)
2. How can this complement the launch of both a P4P measure for blood pressure management, and a HEDIS “Relative Resource Use for Uncomplicated Hypertension” measure for 2008?
3. Data for presenteeism and productivity loss does not seem intuitive (I have reviewed this in depth and we can bring in clinical champions to verify)
4. Partners and aligned interests (will do due diligence to support cooperative business models of partners)
5. How to engage patients in things like biometric monitoring and blood pressure control (will look at plan design options, but most importantly will go to the factory floor, and will bring an employee/patient advisor on to the team)

So that’s the script that goes with the story, more or less. Comment away, and keep in mind that each comment will change the A3 a little every time.

United Hospital Fund, Empire State Building, New York City

On our last day in New York City, Rachel and the United Hospital Fund arranged for a presentation on patient-centered health information technology to the New York Business Group on Health, at UHF-NYC headquarters in the Empire State Building.

As I do with most presentations, I started with a thought provoking question, and this day’s was “When was the last time you looked at your medical record?” The responses, as expected, were extremely varied. Most had never seen their medical record, or seen it in disconnected parts. There were some answers that went like this: “I have seen my claims data in a PHR, but not my medical record.” I thought it was interesting that people were able to differentiate between claims data and a medical record.

At the same time I said, “I wouldn’t be here talking about this if I didn’t think you could do it,” and I meant it. As I posted previously, New York is having great success implementing EHR’s through their PCIP project, and are about to add patient access to these systems. A strong purchaser community can bring the next level of integration - that of a wellness ecosystem.

Several audience members pointed out, accurately, that there are things that can be done in an integrated health system that cannot be done in a dis-integrated one. At the same time, there was sharing of some innovative projects that are happening in the health plan community as well as the purchaser community. I left as impressed with the possibilities as I was when I came.

When I looked out the window at the brewing snowstorm at the end of my talk, Rachel reminded me, “You’re still going to Queens.” Of course I was, and I’m glad I did. More on that in the next post.