Is this the same old song and dance, my friends?
By George Martin, MD – Senior Medical Director for Health Integrated

The ACA sets forth only broad guidance in defining essential health benefits, and that guidance is ambiguous—some would say contradictory. First, EHB “shall include at least” ten named categories of health services per Section 1302. Second, the scope of the EHB shall be “equal to the scope of benefits provided under a typical employer plan.” Third, there are a set of “required elements for consideration” in establishing the EHB, such as balance and nondiscrimination. Fourth, there are several specific requirements regarding cost sharing, preventive services, proscriptions on limitations on coverage, and the like. Taken together, these provisions complicate the task of designing an EHB package that will be affordable for its principal intended purchasers—individuals and small businesses. The Department of Health and Human Services (HHS) has been charged with designing the EHB plan and enlisted the Institute of Medicine (IOM) to assist.

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Care Coordination – The Patient Perspective
By George Martin, MD – Senior Medical Director for Health Integrated

So how will a patient know that their care is being coordinated? Consider, if you will, three levels of interaction as we enter The Twilight Zone of the ideal care coordination scenarios.

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Building a shared vision of how care should be delivered
By George Martin, MD – Senior Medical Director for Health Integrated 

The inpatient setting remains the most costly, intensive and dangerous of places to receive medical care. The, quite accurate, scenario presented in last week’s blog demonstrates the need for such a function in the inpatient setting. Most inpatient facilities have a department that should provide the service, but few live up to the reality.

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The basics of care delivery are broken. And must be fixed … now.
By George Martin, MD – Senior Medical Director for Health Integrated

The telephone conversation went something like this:

“Good morning.  This is Stan Smith,” I said.

“Hello is this Mr. Smith?,” came the response.

“Yes, this is Dr. Smith. How can I help you?,” I replied

“Mr. Smith, this is Delilah, your wife’s case manager and I need your home address,” said the voice at the far end.

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Limited Resources – Targeted Care
By George Martin, MD – Senior Medical Director for Health Integrated

In July 2008, Congress enacted the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 (P.L. 110-275) which restricted enrollment in chronic condition Special Needs Plans (CCSNPs) to special needs individuals that “have one or more co-morbid and medically complex chronic conditions that are substantially disabling or life-threatening, have a high risk of hospitalization or other significant adverse health outcomes, and require specialized delivery systems across domains of care.”

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Customers, Suppliers and Other Confusing Relationships
By George Martin, MD – Senior Medical Director for Health Integrated

In the world of business and quality improvement, relationships are important, well defined and generally obvious. In the world of healthcare delivery, they are no less important but not as well defined and sometimes not at all obvious. So let’s start by defining  each role and then examine their relationships in the health care context.

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Handoffs and the coordination of care
By George Martin, MD – Senior Medical Director for Health Integrated

Change comes to medicine in various ways. Some are obvious and others are obscure. One obvious change is that of interventions for heart disease. Who does not know someone who has a bypass operation or a stent placed for ischemic heart disease? Another is the use of laparoscopes for abdominal surgery. An open cholecystectomy (gall bladder removal) used to require six weeks of recovery and inpatient care. Now it is an outpatient procedure with return to normal activity is a few days.

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How do you define a Useful Measurement in Healthcare?
By George Martin, MD – Senior Medical Director for Health Integrated

For those of you who remember basic math, the following formula will be familiar: 1/0 = ∞.  This is often referred to as infinity.  Dividing by zero fails to yield a useful number.  This is a useful concept to remember, both in healthcare and business.  In medicine, the concept is useful because of the way we have defined outcomes measures.

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Send us your tried and true examples of care coordination gone well…or not so much.
By George Martin, MD – Senior Medical Director for Health Integrated

For the past year we have discussed solutions that can provide for improved clinical outcomes based on care coordination activities. While much of the discussion has been focused on practical examples of effective care, coordination seems to be just beyond reach. The interest here is in comprehensive solutions of care coordination across the continuum; that is to say encompassing the comprehensive needs of individuals. Solutions should address needs ranging from those of severely ill complex patients, disease specific solutions and health management for those not yet ill. We would like to actively pursue how those solutions came about and the impact on care.

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Improving the ER Experience: It’s About the Money
By George Martin, MD – Senior Medical Director for Health Integrated

Our daily medical journal, The Wall Street Journal, Tuesday, August 2, 2011 presented an interesting article about the realization that loss of emergency department patients is seen as a problem by the hospitals with which they are associated.  This is a relatively new phenomenon so worthy of reporting, but not for the reasons suggested.  Hospital administrators have come to the realization that most of their inpatient admissions come from the emergency department.

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