Advisory Group Adjust: Charles Milligan, Jr., Center for Health Program Development & Management

Charles Milligan, Jr., is the Executive director of the Center for Health Program Development and Management, University of Maryland, Baltimore County. I have to insert here that Chuck is also an alum of the University of Calfiornia, Berkeley School of Public Health…

The Center’s Mission is “…to work with public agencies and nonprofit community-based agencies in Maryland and elsewhere to improve the health and social outcomes of vulnerable populations in a manner that maximizes the impact of available resources,” and Chuck brings his experience here as well as experience supporting diverse populations in California in the areas of health care law and policy.

Chuck stimulated a very key conversation that resulted from a little confusion of my part (as I have now surmised). We talked about “PDCA cycles” and the idea that in the Toyota Motor Company, 80% of time is spent on planning, 20% on execution, the opposite of some American Companies. In our discussion these concepts seemed at odds, because as Chuck pointed out, policy makers benefit from quick movement from planning to execution so that they have something concrete to work off of.

Chuck also provided guidance on consumer involvement, that as we look to readily available sources of input, we should also look for not-so-readily available sources of input, because community boards and the like may not be truly representative in every case.

As Maryland’s leading public applied research organization for Medicaid Managed care, the Center is working on appropriately adjusted outcomes measurements that support reimbursements, or as Chuck stated, “report cards that are fair.” His group is also working on an electronic health risk appraisal and the impact on utilization before and after.

With UMBC itself, Chuck alerted us to a forum on behavioral health issues on campus, that will touch on issues of confidentiality and safety, which will happen on November, 27.

The Adjust: I couldn’t wait to resolve the issue regarding “P” from PDCA and “Planning,” and referred that question out to some experts in the LEAN world, which is detailed on the DailyKaizen blog in this post. The adjust, therefore, is in my opinion to keep going by rapidly improving what we do, and the 80% time planning spent happens in the P, C, and the A parts of the cycle. In that respect, Josh and I are doing regular checks on what we are doing. I am also working on setting up a visual system for the work (I will post the picture here, of course).

Chuck is one of the experts on our group regarding reimbursement and care of vulnerable populations, so as with other members of the group, we would like to check on what is happening in this arena. We are already doing that a bit based on the guidance by working to arrange discussions with payers in communities we are visiting. We did this in Boston, and are working to do this in California, our next stop.

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I want to reiterate that that Chuck is entirely correct in his points about reimbursement and incentives. In the advisory group meeting, Chuck pointed out that there are both the immediate perverse incentives in most practice settings to engage in patient-centered care as well as the long-term issues related to enrollment churn that make it difficult to recoup investment in those interventions that have clear long-term financial rewards.

In our shadowing, we have encountered some clinician reluctance to engage in secure messaging and related activities due to these perverse incentives, and we will continue to monitor it closely. Although the incentive structure is something that will be hard to address in the first phase of our PCHIT work, there is no doubt that it will be something for us to grapple with throughout and consider when we develop recommendations for advancing PCHIT implementation in the future.

It also fits into the efforts of the IxAction Alliance's Ix Payer Workgroup. The Workgroup has developed a set of criteria regarding what constitutes information therapy (Ix) that we are sharing with accreditation, pay-for-performance (P4P), and provider recognition programs. The goal is to create more explicit market rewards for Ix and other patient-centered interventions in accreditation and P4P efforts.


Ted Eytan, MD