On Nov. 9 and 10, Community First hosted two mornings of meetings facilitated by Harold Miller, CEO and president of the Center for Healthcare Quality and Payment Reform and sponsored by the Network of Regional Health Improvement Collaboratives. ADVERTISING On
On Nov. 9 and 10, Community First hosted two mornings of meetings facilitated by Harold Miller, CEO and president of the Center for Healthcare Quality and Payment Reform and sponsored by the Network of Regional Health Improvement Collaboratives.
Twenty-five influential leaders from all sectors participated. These included the CMOs from three health plans, the CEO and board chair of Hilo Medical Center, the administrator and former president of the East Hawaii IPA, the CEO and board chair of Bay Clinic, the local Federally Qualified Health Center, local business leaders and the managing director of Hawaii County. Not all could attend both days, but Miller commented that the breadth and level of leadership at the table was rare nationally.
I think we need to remember that and be encouraged by our progress. When I look back, I think we’ve done a lot, but when I look forward, the steps we must take seem endless. We took another significant step forward at these meetings, though, and let me share some of the noteworthy thoughts and lessons.
1. A real community, a unique opportunity and a sense of urgency.
In addition to the strong sense of community, East Hawaii has another unique asset in its relationship with Miller. During the course of several visits the past two years, Miller has come to know the local issues and personalities and developed relationships with people in the health care system and in the community. He is thus particularly effective in presenting the national context to inform local decision-making and also is effective in facilitating the open and straightforward discussions that move the community forward.
We are creating a sense of urgency to overcome the gravity of the status quo. Two weeks before the summit, the chambers of commerce hosted a lunch presentation about the crisis of health care costs titled, “Making the Invisible Visible: The House Is Burning.” In 2012, the Congressional Budget Office published a slide titled “Wake Up Folks, It’s the Health Care.” It showed health care costs outpacing spending on Social Security, defense and other mandatory problems by far. We need a sense of urgency to make change happen.
2. Three principles for the adaptive challenge.
The technical challenges in transforming payment, information integration and care coordination are daunting by themselves, but without addressing what Ron Heifetz calls “the adaptive challenge,” even a correct technical solution can’t make progress. The adaptive challenge involves developing new ways stakeholders relate to each other, new ways to think about entrenched problems and address the potential losses of each stakeholder, and enough trust to proceed in the face of disruptive uncertainty. Community First is uniquely situated to address the adaptive challenge.
Our work is guided by three principles: “Only Together,” “Make the Invisible Visible” and “Try, But Don’t Expect to Get It Right the First Time.”
“Only Together”: For a small, rural place such as East Hawaii to have a say in how health care in our community will work, we have to come together. The physicians, the hospital and the clinics have to collaborate and health plans have to partner with them to create an intelligent, efficient system of care.
“Make the Invisible Visible”: People too often value harmony over truth and make the visible invisible. In the long term, however, harmony can only come from truth, which is the basis of the trust that is needed for collaboration on transformative projects.
“Try, But Don’t Expect to Get It Right the First Time”: We believe that “the house is burning.” We need to act rather than just discuss, recognizing that corrections will be needed and trusting that these adjustments will be made collaboratively.
3. The tension between the desire for centralized, scalable systems and the necessity of community-centric solutions.
Health plans seek scale and standardization to manage operational complexity. Particularly in rural communities, however, health care is local, and communities need flexibility in redesigning the system of care that will leverage assets and compensate for weaknesses. Financing and governance structures must be developed that give the community authority and responsibility for managing the total, accountable medical spend but which minimizes customization and increased administration for health plans. For example, Hospice of Hilo has a beautiful facility for which the community has contributed significantly. To care for someone here costs $700 a day, for which hospice is reimbursed only $300. However, the $700 a day is far less than inpatient costs at the hospital. We need to redistribute financial resources to promote better, higher value care without unintentionally impairing essential services.
What is not sufficiently recognized is the operational complexity put on small private practices. Since health plans want to have their own programs and processes for the sake of their efficiency which gives them competitive advantages through standardization, private practices, which have the least organizational capacity of all, have the impossible task of accommodating the different contracts and requirements of the different health plans. Rather than being health plan-centric, the system needs to be community-centric and health plan-enabled, but achieving this would take collaboration of the highest order from all. Instead, the consensus was to implement the following two initiatives in 2017.
4. From best heart care to best palliative care for serious chronic diseases.
We had a best heart care initiative in 2016 that was designed to improve care throughout the continuum of heart disease, but it ended up focusing on patients admitted to the hospital for heart failure, either referring them for care coordination or to “supportive care,” palliative care without giving up curative care. What seemed like a simple workflow was surprisingly difficult to implement: The hospital was not used to producing the reports needed; primary care physicians were too busy to make referrals; and hospice was used to working with patients who already had accepted the imminence of death. After much effort, this workflow was established and we decided to use this for patients with other serious chronic diseases.
5. Complex patient centered medical home (C-PCMH) and an urgent care clinic.
If trends in utilization continue, HMC will be facing a need to expand its emergency department and inpatient capacity which would be a major capital expense. ED is a significant profit center for the hospital, while Medicaid admissions, in general, result in significant losses. To capitalize on the synergies of HMC relocating its Family Residency Program to be next to the ED at the main entrance of the hospital, we agreed to create a medical home for the most expensive, complex patients who were frequent users of the ED or inpatient services and did not have a primary care physician. These patients are mostly in the Medicaid population. It was further agreed to establish an urgent care clinic at the hospital for patients who do have a PCP, especially those in the East Hawaii IPA, rather than trying to have each small PCP practice develop evening and weekend hours for their patients. This medical home would need to provide comprehensive case management and have the flexibility to spend funds to meet the nonmedical needs of patients to decrease overall medical expenses.
6. Hopefully not just empty discussion.
In order for us to succeed with the best palliative care and C-PCMH/urgent care projects, it is critical that each organization make it a priority for their own organizations. It also is critical that a project structure be established for each initiative. It was decided that each initiative be championed by a community leader and managed by project directors. For best palliative care, Karen Maedo will be the community leader and Brenda Ho, CEO of Hospice of Hilo, will be the project director. For C-PCMH, I will be the community leader and Dan Brinkman, CEO of HMC, and Mike Sayama, ED of Community First, will be the project directors. The community leaders and project directors will convene the rest of their work group.
As this year comes to a close, I’d like to thank you deeply for all the support we’ve received. Without it, we would not be able to continue our work to improve health and health care in our community. In 2017, I’d like to encourage you to become more informed about the issues surrounding health care and even more importantly to take care of your own health. Best wishes for a happy and healthy new year.
This column was prepared by Community First, a 501(c)(3) nonprofit organization led by KTA’s Barry Taniguchi, and supported by a volunteer board of local community leaders. Community First was established in 2014 to help the community respond to the health care cost crisis and support initiatives that change health care from just treating disease to caring for health. To learn more about Community First visit CommunityFirstHawaii.org.
