High Performance Health Care

On November 6, we will once again be presenting the UST Executive Conference on the Future of Health Care. We are very excited about the outstanding speakers who will be making presentations. Although this year has been dominated by health care reform, there are many significant changes occurring in health care delivery and we believe we have identified trends and speakers that are leading change in the system.

This year’s conference is “Where Innovation and Quality Will Take Us” and is presented in partnership with LarsonAllen and Fredrikson & Byron.

The conference will feature keynote speaker George Halvorson, Chairman & CEO, Kaiser Foundation Health Plan and author of Health Care Will Not Reform Itself (2009).

In addition, it will feature lively panel discussions on:

Innovators on the Fast Track – Breakthrough thinkers reveal their new models of health care excellence.
Featured speakers:
o Lou Cornacchia, President & CEO, Doctations, Inc.
o Marcus Osborne, Director of Health Clinics Design & Development, Wal-Mart Stores, Inc.
o Dr. Garrison Bliss, President & CMO, Qliance Medical Management

Providers Revolutionizing Quality – Organizational leaders share how their forward-thinking quality initiatives protect and enhance their bottom lines.
Featured speakers:
o Diane Gross, Vice President/General Counsel, Poudre Valley Health System – Fort Collins, CO (2008 Malcolm Baldrige National Quality Award winner)
o Ken Paulus, President & CEO, Allina Health System – Minneapolis, MN
o Dr. Edward Shultz, Director of Information Technology Integration, Vanderbilt University Medical Center – Nashville, TN

Registration is now available at http://ustfutureofhealthcare.com/

Posted by Dan McLaughlin at 03:25 PM | Permalink | Comments (0)

Depends on what the question is. Kathy Dodge from Bloomberg News called me this past weekend. She is visiting HealthPartners, a staff-model HMO in Minnesota which doesn’t want to be called that and is legally a co-op, and heard I was a skeptic. Not at all, I told her. “I’m one of those health reformers who believe everything we need to do to change the system has already been invented.” For example, if you are a multi-specialty medical practice group which also owns your hospital and an insurance plan, you can share the benefits of your quality and efficiency improvement with your staff and your plan members. Makes no difference whether you are legally organized as a for-profit, nonprofit, or cooperative. The tax breaks under state and federal law which go with the nonprofit theory of community benefit, or with the co-op in some states, is a subsidy that can make them more competitive than tax-paying for-profits.

You can find purchasing cooperatives in some states as well, including Minnesota. Usually they are financing access to public programs for specially eligible populations. Senator Jeff Bingaman (D-NM) and I authored legislation to make them available to individual and small group purchasers back in 1990-91. It would have made it possible to spread the risk of small groups across much larger numbers of members, ages, gender, and medical conditions. Sort of like insurance exchanges might today. At the same time, I was doing small group insurance reform legislation with Senator Daniel Patrick Moynihan (D-NY). Adopted from Delaware and Minnesota models, it would require insurance companies to compete on risk assumption, not avoidance, with guaranteed issue (no pre-existing conditions limitations), guaranteed renewal with limits on premium price changes through rating bands, as they are called, and others.

If you are a member of Congress and genuinely interested in health care cost containment, try real health insurance reform. Repeal the McCarron-Ferguson Act as it applies to health insurance so every insurance company can sell anywhere in the country if it plays by the same rules, not 50 different rules. Do what Moynihan and I tried for all plans and add an evidence-based basic benefit, some cost-sharing rules, standard claims process for all companies and all benefits, and a few other things I don’t understand and we’ll save billions. Then ask Bingaman to bring back the Health Insurance Purchasing Cooperative (HIPC) instead of the Association Health Plan and you’re good to go. You bring Grassley and Hatch on board by jettisoning the public plan and you give Kent Conrad the authority he seeks for co-ops that maximizes the value of private insurance, however organized, rather than calling it “keeping them honest.”

At that stage, even CBO should be able to score savings and you can go on to creating legislative authority to pay more appropriately for high performing health systems like HealthPartners or Intermountain Healthcare in Utah or Group Health Cooperative of Puget Sound in Seattle. That list goes on and on with examples that can be emulated even in McAllen, TX; Miami, FL; Los Angeles, CA and New York City. If the local medical-industrial-political complex is willing.

Last word. Co-ops are not THE answer. THE answer is competition and consumer choice. Of readily comparable consumer products. Like health insurance and health care. I’ve read about AHIP spokespersons who imply that competition means the more health insurance in a community, the more consumer choice and competition. Wrong. It’s no accident that the lowest utilization, lowest per member cost, and highest quality care is in states with virtual monopoly insurance companies like the Blues of Montana, North Dakota, Iowa, and Maine.

They are also nonprofit with a community benefit, not shareholder benefit, obligation. It's what happens when insurers are not adversaries of providers and purchasers and patients are people and citizens, not just consumers. Minnesota is the only state to require its HMOs to be nonprofit.

The same can be said for real insurance competition where only a few plans are in the market able to leverage on behalf of health care improvement. With five large plans in a metro market, providers have to respond. With 100, there are no incentives for providers to change or for informed choices by consumers. Republicans believe markets are made up of hundreds of medical specialty companies from which consumers in need make choices. To take on the problem of chronic illness they took a good idea, called special needs benefits, converted it into private Special Needs Health Plans in MMA 2003, paid them lots of Medicare money, and today we have thousands of these plans in illness specialties you can't even imagine. Are costs coming down? No. Just the opposite.

What makes for health system reform? Cooperation, not competition as we currently know it. In medium-sized Wisconsin communities with two medical clinics and hospitals, they call it “co-opetition.” Doctors cooperating to keep people well and out of hospitals and competing on the most productive and efficient use of hospitals, when needed.

Posted by Dave Durenberger at 03:10 PM | Permalink | Comments (0)

Grace Marie Turner rose to policy prominence in Washington, D.C., as part of Senator Bob Bennett's (R-UT) staff to play a relevant role in health reform. Bob's father was in the Senate and he has always been a rote, reasonable conservative from the state of Intermountain Health Systems. Bob had no committee authority on the subject, so Bob Dole appointed him to bring GOP Senate’s left and right together. After Clinton reform failed, he carved out a place no one wanted on privacy policy and suffered the fate designed for anyone who ventures into this area. So he asked Grace Marie to head up a group of eight center-right health policy tanks to evolve principle policy reform.

Out of that effort came Consumer Driven Health Care (CDHC), which latched onto the new Bush Administration economic ideology and brought us the revival of the Medical Savings Account and the Golden Rule Insurance Company (since acquired by UnitedHealthcare for $850 million) consumer choice of individual high deductible insurance. By 2001, the GOP had driven most all of its centrist members out of the Senate and the House and with them much of their health policy leadership on authorizing committees. Only Bill Thomas was left at Ways and Means and he was co-opted by other issues and his persona and the resurrection of Newt Gingrich with his medical industry-funded health care transformation.

About this time in 2003, the GOP White House and congressional majorities working on Medicare Modernization decided to turn Medicare prescription drugs, AARP, and the seniors voting bloc into a reelection asset for 2004. But they needed a way to keep real conservatives on board a "modernization" bill that would spend one trillion dollars over ten years without raising taxes on anyone but the rich Medicare eligibles. Sound familiar? They found it in converting MSA to Health Savings Accounts (HSA) and brought Gingrich in to the House caucus to sell anti-spending conservatives on CDHC. With the help of a couple conservative Democrats (all of whom are still around), they succeeded.

Most of the Bush White House proponents of CDHC/HSA have gone off to sell a variety of their policy off-spring - either insurance or related CDHC products. Grace Marie has remained the rock of principle for conservative consumers. She is articulate and reasonable and has morphed from "skin in the game" insurance products as health care reform vehicles to add support for any consumer information that hasn't been generated by a government or quasi-government agency (that's anti-free market).

More than anyone, Grace Marie has made the "reasonable case" for opposition to "government-run" health care and in her August 21, 2009, editorial she believes that she and the GOP/conservative/CDHC industry approach is winning the current policy battle. Now, I don't agree with a lot she advocates, but she is a reasoned advocate without the intemperate approach of current congressional reform opponents.

She is also wrong on the "turning of the tide." You know the joke about "I don't belong to any organized party; I'm a Democrat?" Well, believe it or not, Democrats in Congress and the White House will find policy consensus on a major reform bill and Republicans, single payer insurance advocates, and CDHC insurance advocates will have to learn to live with it.

We'll have the Republicans to thank for it because their nearly unanimous opposition to Obama will force the old-line Democrats to listen to and find consensus policy with the new and more conservative Democrats. If these people are anything like Congressman Tim Walz (D-1st MN), there will be a bill the president can sign, people in Minnesota can learn to like, and the political result will be that President Obama looks like a leader and the Republicans look, for the third straight election, like they enjoy ignoring the problems of health care access and affordability.

Posted by Dave Durenberger at 02:12 PM | Permalink | Comments (0)

I learned a lot about conservative economics and the role of government from Marty Feldstein during my three terms in the U.S. Senate, particularly around health policy. I also know he's no expert on health care delivery and the variety of health systems which make up this interesting country of ours. His recent Wall Street Journal article, “ObamaCare Is All About Rationing,” is the second opinion he's offered on Democratic health reform policies which illustrate why he needs to better understand medical economics.

He raises two policy issues in this opinion. The first is the over-consumption of health care services in this country and the role that health insurance and insurance tax treatment play in encouraging it. With that, I have little or no disagreement. With his tax reform solutions, I'd only suggest that tax and income equity might dictate something other than a regressive HSA as a publically financed cure.

The second issue is the over-utilization of health care services encouraged by medical professional practice patterns, the encouragement of over-utilization by fee-for-service payment policy, and the discouragement of conservative, results-oriented practice by the same fee-for-service policy. Obama and Democrats in Congress, with help from blue dog Dems in states like Minnesota, want to use comparative performance information to enhance consumer choice. Feldstein chooses to call any effort at comparing physician performance “rationing.”

He is dead wrong. Just as he was in an earlier Op-Ed declaring the difference in practice results and costs between New York and Minnesota is due to genetics. He can check with people who live in Hawaii, northern California, the Pacific Northwest and the upper Midwest and New England to see whether they think they are being denied access to needed health care services. Try Group Health of Puget Sound or HealthPartners in Minnesota. Anyone in North Dakota, with the lowest PMPM premiums in the country. Grand Junction, CA; Ogden, UT; LaCrosse, WI; Hershey, PA, and a long list of others.

Physician leadership makes all the difference in the world. So do states with a commitment to expanding coverage to as many citizens as possible and to enhancing the use of quality and performance data to better inform consumer choice of health plans and providers.

Posted by Dave Durenberger at 10:22 AM | Permalink | Comments (0)

Sin taxes are as old as humanity. Someone has always been able to persuade a government that taxing any beverage with any alcohol content will discourage its consumption. In Oakland, CA, promoters of marijuana have public support behind taxing pot. In this case, to enable its legal consumption. Taxing tobacco has always been sold as a way to encourage smoking cessation. Because obesity, unlike many other diseases, is usually the result of individual choices about diet and exercise, it is becoming popular to tax fat in order to discourage its consumption.

Researchers inform us that Americans are becoming much more obese in the last 30-40 years. It is true that personal convenience is a major reason for changing our exercise and diet habits. The response to convenience is a food industry which is funding a nutrition science industry to produce a variety of “healthy” food elements which then become required food labeling which then excuse price increases on convenience foods. It is just short of a remarkable phenomenon in America that boys and girls and men and women are turning out in increasing numbers in exercise spots and that health and fitness clubs are in every hotel, hospital, and highway rest stop. It is also remarkable that the organic food movement is catching on quickly. Starting with “buy locally” – which, of course, has been quickly translated into “support your local any store (including Wal-Mart.)”

I have read and enjoyed In Defense of Food by Michael Pollan. My wife Susan and I enjoyed Food Inc. at our San Rafael, CA nonprofit movie theatre. It describes how four very large U.S. companies control access to and the quality of most of the essential ingredients of the food Americans consume. That agriculture company Monsanto has a corner on wherever soy beans end up. That the family farmer is anything but and is usually a victim of the co-op he/she has helped create to preserve a socio-economic system that no longer exists – except in Congress. Where it is used to enrich production food rather than production agriculture. That two-thirds of us prefer white meat to the dark meat so the chicken industry is producing – in 48 days from hatch to super market – chickens whose breasts are so large the chicken is unable to walk.

Posted by Dave Durenberger at 03:53 PM | Permalink | Comments (0)

Everyone knows what an “earmark” is. It is what members of Congress do with your money to buy your election support. It is an appropriations bill language to spend some millions of dollars on your business, your airport, your new highway or agriculture research project – in exchange for your vote. It is how members of the Senate and the House sell their votes to the Appropriations Committee chair in exchange for their support of his bill. Usually health care earmarks are confined to the Labor, Health and Human Services, Education and related agencies Subcommittees of Appropriations. This year, if President Obama insists on a health reform bill, it will also apply to some $2.5 trillion in health care services spending as well. The president decided to let the Congress write the health reform policy bill. Then the Republicans decided to take a stand against new spending, and any reduced old spending on behalf of their medical industry friends (especially medical technology and insurance).

At that point the Democrats couldn’t get to universal coverage without cost savings and couldn’t get to savings by reducing spending on unnecessary and unnecessarily costly medical and insurance services. At that point it became possible to win votes by bartering for modifications in insurance reform (reduce the effectiveness of the public plan); or carving out exceptions to coverage mandates for small businesses; or scaling back the high income surtax; or paying states more to increase Medicaid coverage; or giving PHARMA breaks. And the bartering for votes has only just begun. The hopes for real policy reform will have to come with authorization to CMS to begin to tie Medicare and Medicaid payments to health outcomes.

Posted by Dave Durenberger at 11:01 AM | Permalink | Comments (0)

As the health care industry focuses its energy on trying to influence health care reform, it is sometimes easy to ignore the basics of leading a high performance organization. One fundamental activity for all organizations is governance and, unfortunately, this is frequently done poorly.

At the recent summer meeting of the Minnesota Medical Group Management Association my colleague, Professor Fritz Wenzel, provided a very useful overview of the characteristics of functional and dysfunctional boards of directors. He also outlined strategies to improve the performance of any board. As part of this presentation he also had a number of very specific recommendations to resolve common board problems. Here are some excerpts from his presentation:

Board effectiveness
Boards can be analyzed from four perspectives:

1. Process – How is board focus determined, how are decisions made, and how are meetings conducted?
2. Structure – What is the board composition, what are board roles and expectations, how are members oriented?
3. Behavior –How do board members act with the other board members, the organization and the external environment?
4. Performance – What is the board accountability for the organizational performance and what tools does it use to monitor execution?

Boards that pay attention to all of these questions will have superior performance.

Board Process Problems
Here are the top ten board process problems and some possible solutions:

1. Board attempts to micromanage – Clarify roles and keep focus.
2. Can’t make decisions and not united when they do – Formalize a decision matrix and create formal communications systems and deadlines.
3. Meetings last forever and are unproductive – Provide a formal timed agenda, document action plans and follow through.
4. Board members are recruited for the wrong reason – Establish criteria for board membership and formalize the process.
5. Roles are unclear – Document expectation and provide board education.
6. Board members lack organizational/strategic knowledge – Provide education and consider an external board assessment.
7. Members are not prepared – Call on members, revisit their role definitions.
8. Board practices “Group Think” – Assign a member to be “devil’s advocate” and institute board evaluations.
9. There are power struggles/factions – Deal directly and individually with members and heighten engagement of the total board.
10. A completely dysfunctional member – Options in increasing order of intensity: wait until term is over, off line discussions, neutral observer at board meetings, gracefully remove

Fritz Wenzel and his colleague Deborah Walker Keegan will present an extended workshop on this topic at the national Medical Group Management Association meeting on October 11-14 in Denver. If you are attending this conference, consider attending this session for a more in- depth look at this ongoing leadership challenge.

Posted by Dan McLaughlin at 01:29 PM | Permalink | Comments (0)