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	James L. Holly, M.D.

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Letters - Optimetra March 23, 2017 Summary of Meeting

Optimetra
STARS-PLUS Medicaid

March 23, 2017

We enjoyed our meeting with you this morning. Hopefully, you will be able to translate some of the qualitative aspects of our discussion to your constituency. I will try and reconstruct some of our discussion which may have the most value to your report.

First, the premise that “convenience is the new word for quality,” (see the following for the full presentation: http://jameslhollymd.com/Presentations/HIMSS-2012-Leaders-and-Innovators-Breakfast-Meeting) was broached in response to one of the challenges experienced by healthcare providers in “addressing significant social determinants of health in each region.” In relationship to transportation we talked about the stress on patients to make a plan days in advance and then spending an entire day in getting to and from a clinic visit.

Convenience for the patient, which
Results in increased patient satisfaction, which contributes to
The patient having confidence that the healthcare provider cares for the patient personally, which
Increases the trust that the patient has in the provider, all of which
Increases compliance (adherence) in the patient obtaining healthcare services recommended, which
Promotes cost saving in travel, time and expense of care, which
Results in increased safety, quality of care and cost saving for the patient

This requires intentional efforts to identify opportunities to:

Schedule visits with multiple providers on the same day, based on auditing the schedule for the next 30-60 days to see when a patient is scheduled with multiple providers and then to determine if it is medically feasible to coordinate those visits on the same day.
Schedule multiple procedures, based on auditing of referrals and/or based on auditing the schedule for the next 30-60 days to see when a patient is scheduled for multiple tests or procedures, and then to determine if it is medically feasible to coordinate those visits on the same day.
Scheduling procedures or other tests spontaneously on that same day when a patient is seen and a need is discovered.
Recognizing when patients will benefit from case management, or disease management, or other ancillary services and working to provide the resources for those needs.

Convenience is a process, not an outcome, of coordination of care: therefore, SETMA formed a Department of Care Coordination and created a convenient method for enlisting that department in a patient’s care.

It was only through this analysis that we accepted "convenience" as a worthy goal of quality care as opposed to it only being a means of "humoring" patients. This fulfilled SETMA's goal of ceasing to be the constable, attempting to impose healthcare on our patients; and, to our functionally becoming the consultant, the collaborator, the colleague to our patients, empowering them to achieve the health they have determined to have.

Second, in regard to Star-Plus Plans who refuse to pay for services unless the provider named as the PCP delivers the services was discussed under the premise that “the new word for continuity of care is not personality-based care but the continuity of a robust, accessible and intuitively design electronic data base” such as that developed by SETMA. In that SETMA practices “electronic patient management,” and in that the patient’s data base is available at every point of care, it is possible for the same quality and safety level of care is possible regardless of which member of SETMA’s team is delivering the care. SETMA addressed the frustration we experience when _____ will not pay for the excellent services we deliver because for the convenience of the patient a provider other than the one on their insurance card sees them. As there is no reason for this, we assume it is a method used by _____ not to pay for services delivered to their beneficiaries no matter how high quality those services are.

Third, we talked about SETMA’s Model of Care which is described at the following link: http://jameslhollymd.com/The-SETMA-Way/pdfs/setma-model-of-care-pc-mh-healthcare-innovation-the-future-of-healthcare.pdf. This discussion addressed one of the elements of your research as to “challenges with obtaining timely clinical and transactional data and/or collecting and reporting on quality measures.” The five steps to SETMA’s Model of Care were addressed:

Tracking over 300 quality metrics on all patients seen regardless of payer class
Auditing by panel, population or provider of the performance on quality metrics
Analyzing by statistical methods the outcomes of our care delivery in order to distinguish between the “mean” or average, which may be good making it appear that our performance is better than it is and the “standard deviation” which will reliably indicate what percentage of a population or panel is receiving excellent care.
Publicly Reporting by provider name on the provider’s performance.
Designing quality improvement methods based on the first four steps.

This model of care has allowed SETMA to reach new heights in quality and safety as is evidenced by our multiple accreditations and awards. (see: http://jameslhollymd.com/Accreditations/pdfs/accreditations.pdf).

Fourth, in addition to adopting a business intelligence software package to healthcare, SETMA has design tools which allow us to analyze opportunities for improving outcomes and performance. Data Analytics in primary care was the subject of my presentation to the Massachusetts Medical Society in 2012 which can be reviewed at: http://jameslhollymd.com/Presentations/The-Importance-of-Data-Analytics-in-Physician-Practice.

The power of analytics was addressed in 1858 by Abraham Lincoln who in his “House Divide” speech said, “If we can first know where we are, and whither we are tending, we can better judge what to do and who to do it.” (see: http://jameslhollymd.com/Your-Life-Your-Health/pdfs/Abraham-Lincoln-and-Modern-Healthcare.pdf) The greatest problem in healthcare today is not that providers’ do not know where they want to go but they don’t know where they are which makes it impossible for them to know what to do to get to whether they know they want to be.

In part this presentation said:

“’Information’ is inherently static while ‘learning’ is dynamic and generative (creative). In The Fifth Discipline, Peter Senge, said: ‘Learning is only distantly related to taking in more information. Classically, taking in more information has been the foundation of medical education. Traditional CME has perpetuated the idea that ‘learning; is simply accomplished by ‘learning more facts.’ Analytics transform knowledge into an agent for change.

“In reality, without analytics, we will neither know where we are, where we are going, or how to sustain the effort to get there.“For transformation to take place through knowledge, we must be prepared to ask the right questions, courageously accept the answers and to require ourselves to change. Healthcare transformation, which will produce continuous performance improvement, results from internalized ideals, which create vision and passion, both of which produce and sustain ‘creative tension’ and ‘generative thinking.’ Transformation is not the result of pressure and it is not frustrated by obstacles.

“In fact, the more difficult a problem is, the more power is created by the process of transformation in order to overcome the problem. The greatest frustration to transformation is the unwillingness or the inability to face current reality. “Often, the first time healthcare providers see audits of their performance, they say, ‘That can’t be right!’ ‘Through analytics - tracking data, auditing performance, statistical analysis of results - we learn the truth. For that truth to impact our performance, we must believe it. Through acknowledging truth, privately and publicly, we empower sustainable change, making analytics a critical aspect of healthcare transformation.

“While an Electronic Health Record (EHR) has tremendous capacity to capture data, that is only part of the solution. The ultimate goal must be to improve patient care and patient health, and to decrease cost, not just to capture and store information! Business Intelligence (BI) statistical analytics are like coordinates to the destination of optimal health at manageable cost. Ultimately, the goal will be measured by the well-being of patients, but the guide posts to that destination are given by the analysis of patient and population data.”

Fifth, we discussed how socially responsible providers, who care for the poor, the needy, the chronically ill are being punished by the government and by profit-based healthcare organizations. Over the past seven years, Medicare Advantage programs have had a four percent annual reduction in revenue for cumulative reduction of 28%. On top of that, our IPA has a $1,700,000 tax imposed by the Affordable Care Act which increasingly makes it difficult for us to continue to operate the way we have. Those who refuse to care for these patients are rewarded with high, uncontrolled reimbursement.

The need for the STAR-Plus Medicaid program is to reward those providers who are controlling cost, maintaining and increasing quality and safety and providing measurably excellent care with:

Fee-for-service at a competitive rate
Capitation for non-reimbursed services which we provide
Shared savings for producing high quality care at a reduced cost.

Sixth, SETMA has extended the care we provide to the point that we pay for services which are not paid for by health plans. In 2009 SETMA established the SETMA Foundation to which SETMA providers contributed $500,000 a year, until recently. That money was used to pay for care which patients could not afford. Co-pays to see specialists, medications that insurance did not pay for, dental care and other critical healthcare services. In 2009, SETMA paid for the dental reconstruction of a patient who was on nine medications and who had been in the hospital nine time over the previous three years. Since we spend $10,400 of SETMA’s partners’ money to “fix her teeth” she is now on one medication and has not been back in the hospital.

Last summer, on vacation, my wife and I met a young lady while checking into a motel. Later, I returned to the lobby when no one else around and asked her, “Will you do something for me?” She agreed, and I said, “Will you smile for me?” She did and I added, “Have you ever wanted to have your teeth fixed?” She did, and I said, “But you couldn’t afford it?” I then gave her my card, and said, “If you contact me I will see that you get your teeth fixed. “ She wrote me later and said, “Is this too good to be true?” Next week, after a long process, my wife and I will send $19,000 to the dentist and the oral surgeon who will fix this young lady’s teeth correctly and permanently.

Our society would save billions on healthcare by supporting proper dental care for all patients and particularly for those who are young and with diabetes.

Seventh, the Patient-Centered Medical Home model of care will make a huge difference in the future. Health plans ought to promote and support this model of care with capitated payments for PC-MH. With patient activation, engagement and shared-decision making, we really can change the cost trajectory, quality and safety of healthcare. BUT, someone has to acknowledge it with financial rewards for practices to continue pursuing these complicated and costly care methods. By the way, as the above documents, SETMA is the only practice in America accredited by NCQA, AAAHC, URAC and the Joint Commission for PC-MH.

Eighth, we discussed ethnic disparities of care and how SETMA has eliminated those disparities in diabetes and hypertension. (see: http://jameslhollymd.com/Your-Life-Your-Health/ehr-business-intelligence-and-ethnic-disparaties-of-care and http://jameslhollymd.com/Medical-Home/population-health) It is critical that we continue our focus on this area of medicine as we shall.

Ninth, we began a discussion of the relationship between “value, virtue, trust and hope.” Science can treat disease but science cannot produce health. (see: http://jameslhollymd.com/Your-Life-Your-Health/pdfs/value-virtue-trust-and-hope-the-foundation-of-health-improvement.pdf and http://jameslhollymd.com/Your-Life-Your-Health/value-virtue-and-hope-why-do-so-many-do-so-little-about-their-health) This discussion may be the heart and soul of the Medicaid STARS-PLUS program. (see: http://jameslhollymd.com/Transforming-Your-Practice/tcpi-preventive-health-tools)

Technology Can Deal with Disease but Cannot Produce Health

In our quest for excellence, we must not be seduced by technology with its numbers and tables. This is particularly the case in healthcare. In the future of medicine, the tension - not a conflict but a dynamic balance - must be properly maintained between humanity and technology. Technology can contribute to the solving of many of our disease problems but ultimately cannot solve the "health problems" we face. The entire focus and energy of "health home" is to rediscover the trusting bond between patient and provider. In the "health home," technology becomes a tool to be used and not an end to be pursued. The outcomes of technology alone are not as satisfying as those where trust and technology are properly balanced in healthcare delivery.

Our grandchildren's generation will experience healthcare methods and possibilities which seem like science fiction to us today. Yet, that technology risks decreasing the value of our lives, if we do not in the midst of technology retain our humanity. As we celebrate science, we must not fail to embrace the minister, the ethicist, the humanist, the theologian, indeed the ones who remind us that being the bionic man or women will not make us more human, but it seriously risks causing us to being dehumanized. And in doing so, we may just find the right balance between technology and trust and thereby find the solution to the cost of healthcare.

It is in this context that SETMA whole-heartedly embraces technology and science, while retaining the sense of person in our daily responsibilities of caring for persons. Quality metrics have made us better healthcare providers. The public reporting of our performance of those metrics has made us better clinician/scientist. But what makes us better healthcare providers is our caring for people.

Tenth, “white” is the color of my shirts, not the color of my skin. We tend to define people by skin pigment but the inadequacy of that is in the designation of some people as “white” when there are no such men or women on the earth. Because, we believe that this is a vestige of institutional racism, in addition to eliminating ethnic disparities of care, SETMA refuses to perpetuate the use of this method of distinction. SETMA looks for ways of debunking this myth. We label good outcomes as “black” and unacceptable outcomes as “red.” We promote the life and history of Steve Biko (see Cry Freedom)

We discussed many other things but this is a good beginning on a summary.

From you? I would like your response to our discussion today. I look forward to hearing from you.

James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com

Adjunct Professor
Family & Community Medicine
University of Texas Health San Antonio
The Joe R. and Teresa Lozano Long School of Medicine

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center

Related Letters

	Optimetra Research March 23, 2017 Optimetra's Response to March 23, 2017 Meeting Optimetra’s Response to Dr. Holly’s Letter – March 15, 2017

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