This week in health care

This was the week that epic events were scheduled to happen in regard to health care on the national, regional and local levels.

By Thursday, the Supreme Court will in all probability finally have ruled on the constitutionality of the federal Affordable Care Act passed in 2010. That’s the big enchilada, involving the basic structure of an industry that encompasses a sixth of the gross national product. The headlines generated by the Supreme Court decision are expected to surpass those about the British Golden Jubilee and the celebrated Kardashian divorce put together.

On Tuesday, a web-based seminar took place in regard to an ambitious Hudson Valley-wide initiative to advance coordinated, comprehensive primary care. Our region is the locus for a federally supported pilot program for the reorganization of this portion of national health care. According to THINC (Taconic Health Information Network and Community) in Fishkill, at least two-thirds of all Hudson Valley primary medical practices have now adopted electronic health records (62 practices, 182 locations, 831 providers). But their clinical integration into a broader system of health care is only a little beyond its infancy.

And this was of course the widely anticipated week that HealthAlliance of the Hudson Valley (HAHV) would hold two meetings, one in Kingston on Tuesday and the other in Saugerties on Thursday, to inform and to listen to public input on the consequences of the local integrated healthcare system’s serious financial circumstances. Concerned that premature disclosure of its alternatives might exacerbate uninformed community concern, HAHV management exhibited some degree of reluctance to hold public meetings now, but they did agree. With the community already forewarned that drastic change was likely to be necessary, the meetings were widely anticipated. The Daily Freeman on Tuesday outdid itself with the zippy headline “Forum today on hospitals in Kingston,” second in size to that for an accident story, “One dead, two injured.” The Freeman promised to livestream the HAHV event.

Like patients scheduled for serious but necessary surgery, locals involved in the health care industry looked forward to the cataclysmic events of this week with a combination of relief and dread. Sorting out what happened is likely to take months.

Inevitable change

Three conclusions seem obvious. After more than 60 years of inaction, Americans seem to realize that the cost of not completely overhauling the healthcare system is greater than that of overhauling it. Health care is a subject of interest to the entire community.

Secondly, information management is transforming the world of health care, making an unprecedented degree of coordination among providers, payers and patients possible. More parts of the expensive, sprawling and uncoordinated system that is the healthcare industry are being scrutinized and reformed. The process will continue, no matter what happens with HAHV and, in fact, with Obamacare.

Finally, now that the outlines of what’s likely to happen to a couple of the big imponderables, one national and one local, are becoming clearer, there is likely to be an acceleration of attention to solving the huge problems of the industry. The trend toward abandonment of the traditional payment-for-services model, which discourages integrated care, is likely to continue. No matter who wins the next national election, America will turn to some other system.

Happy trails to you

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A park ranger at the Vanderbilt Mansion holds up the patch you get if you walk five trails
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A 3.5-mile trail walk was created in 1991 from Franklin D. Roosevelt’s home and library in Hyde Park south via River Road to the Vanderbilt Mansion by a partnership among the National Park Service, the town of Hyde Park, Scenic Hudson and the Winnakee Land Trust, plus local branches of the Boy Scouts and the Adirondack Mountain Club. Now, 21 years later, the trail consists of eleven sections of approximately 16.8 miles that run (or walk) from Eleanor Roosevelt’s Val-Kill all the way to Norrie Point State Park.

Kathleen Davis, Hyde Park’s recreation director and trails coordinator, is liaison to all the agencies. “It started with a group of Vassar College students involved with the fledgling Hudson Valley Greenway [the proposed trail that will hopefully run from Albany to New York City],” said Davis, “and as we speak we are obtaining easements from The Anderson School, the River Ridge housing development and the Huyler Glen development to connect the remaining spaces. We have secured a $100,000 grant from New York State [Office of Parks, Recreation and Historic Preservation] to develop these new trails.”

The Winnakee Land Trust holds the trail easements across private lands that allow access, and also owns a 100-acre park as part of the trails system. “We work with the town committees and the others to negotiate with landowners and hope to get their approval,” said land trust director Lucy Hayden. “We call it a walkabout, and our aim is to connect every trail in Dutchess County. It’s our 50-year plan, and we keep plugging away at it.”

The walkabout project promotes healthy physical activity such as walking on the trails, which offer dramatic faraway views of the Hudson River and the Catskills, or close-up ones of woodland pools and ponds, streams, waterfalls and picturesque rocky outcroppings, deep woodlands, historic forest plantations, plus carefully maintained ornamental gardens. One can retrace the footsteps of visiting world leaders or Civilian Conservation Corps (CCC) workers in the 1930s or free and enslaved African-Americans who lived here in the late eighteenth and early nineteenth century. Those who walk five Hyde Park trails in one year earn a specially designed free sew-on patch. Walk all eleven trails and earn all five patches issued. The walkabout, which begins every year during Earth Day celebrations, is co-sponsored by the Dutchess County health department.

Instead of walking, you can, as retired IBM planner Bill Ring and his friend Raphael Notin do, run the whole route. In the fall of 2010, Ring and Notin were working with the Winnakee Land Trust mapping trails from Val-Kill to Norrie Point. Ring, who is on the trails committee and is liaison to the town recreation department, remembers the time well. “It was just a beautiful day,” he recalled. “The leaves were down, and everything was so crystal-clear.”

Notin confessed that the project had started as a joke. “We were both amateur runners and we talked about jogging it together,” he said, “but never got to it until I jokingly threw the idea of running all the trails in one go.” That go began at Val-Kill at 9:30 a.m. up and down the narrow trail to FDR’s Top Cottage and around Eleanor’s Walk. Then it passed from Route 9G to Route 9 on the Roosevelt Farm Lane trail. “We ran through the FDR National Historic Site, running through tall forests, meandering along wider sections, looping around vernal pools and magnificent rock ledges,” Notin said. “We then ran northward to the Vanderbilt Mansion National Historic Site and found the clayish sandy trails on which Bill used to run barefoot.” There they could loop down right along the banks of the Hudson River and catch glimpses of other estates.

With seven trails down and four to go, the duo was joined by their friend Chris at the Winnakee Nature Preserve. Then it was through Hackett Hill Park and Pinewoods Park. Nine down, two to go.

“Bill wouldn’t stop,” said Notin. “My knee started to hurt. And Chris had a bad cold. We paused and drove north to find the last two trails at Mills Mansion-Norrie Point, dreaming of the day when we will be able to run a continuous trail between Vanderbilt and Norrie Point. From then on, Chris took the lead and pulled us northward on the White Trail, flirting with the Hudson, then back south toward our finish at the Norrie Point Education Center.”

A native of France, Notin had learned a lot about American history and the national and international significance of the sites and woods they visited. He glimpsed a grandeur in the experience. “Running along with my great and humble friend Bill, I contemplated the idea that the Hyde Park trail system is to Dutchess County what the Freedom Trail is to Boston,” he said. “Both trail systems link sites that helped create the American spirit. In times of great trouble, and opportunity for this country, FDR, Eleanor and a host of others found refuge, resource and inspiration in these woods.”

The first Dutchess County Regional Trails Conference, sponsored by the Winnakee Land Trust and made possible by a grant from the Hudson River Valley Greenway, was held over Earth Day weekend at the Marist College Cornell Boathouse. The conference brought together towns, villages and trail groups from across the county to learn from each other, share resources and help envision the kinds of trails and connections that would result in a truly regional system of trails. The presentations at the conference focused on the practical aspects of funding, trail-building and working in partnerships. Smaller break-out sessions mapped out and discussed potential connections and destinations, given the existing ownership land-use patterns.

You can visit Hyde Park Trails online at: www.hydeparkny.us/recreation/trails. Winnakee Land Trust is at: www.Winnakeeland.org. And the National Park Service rivers and trails program can be accessed at: www.nps.gov/rtca.

Change agents

Kingston environmental educator Julie Noble conducts a maple-sugaring workshop at the Forsyth Nature Center. (photo by Phyllis McCabe

For community organizers, tackling childhood obesity and other results of unhealthy habits is a David-and-Goliath kind of a fight. The marketing of junk food to kids is supported by powerful forces. The computer has replaced the playground as the place where millions of kids spend their time, and America’s ubiquitous car culture make the streets unsafe for children who do want to ride their bikes. The problem of overweight kids, which threatens to reverse the long trend in which each generation outlived the one before it, is a national issue that reverberates locally. A quarter of the kids in Ulster County are overweight.

Healthy Kingston for Kids (HKK), a four-year initiative coordinated by Cornell Cooperative Extension (CCE) and funded by a $360,000 grant from the Robert Wood Johnson Foundation, has devised a multi-pronged approach that addresses the multiple causes of the problem, from the unsafe streets that prevent kids from walking to school to the cultural disconnect kids have with fresh, locally grown food.

HKK is organized into four committees: Safe Routes to School, Complete Streets, School and Community Gardens, and Healthy After-School Snacks. The effort is enhanced by partnerships with at least a dozen organizations, including the Kingston schools and the city government.

Its achievements three years into the project are modest measured against its ambitious goals. Healthy Kingston for Kids is seeking to creating a framework for healthier living.

The community gardens program has already resulted in tangible improvements to the urban environment. But most of the initiatives are longer-term in scope. Meaningful results have been elusive. Progress has been slow.

“We’ve learned changing overall environmental policy systems to reverse obesity takes a really long time,” said project director Kristin Wilson. “We’re really just getting started. We have gotten some new policies passed at the municipal level and are working on school-district policies. Getting a policy passed doesn’t mean that people will follow it. It’s a slow haul.”

Focus on primary care

The United States Supreme Court is scheduled to rule very soon on the constitutionality of the new federal health care law just as some of the more innovative aspects of the law are going to be tested locally. Last week the federal government announced it had reached agreement on a memorandum of understanding by which six major Hudson Valley payers — Aetna, CDPHP, Hudson Health Plan, Empire Blue Cross, MVP and the Teamsters’ health plan — will reimburse selected local medical practices providing comprehensive primary care.

The seven payers have agreed to cooperate with each other and with about 75 selected primary-care providers in the 12-county region for four years. The ambitious — even revolutionary — plan is intended to allow the Hudson Valley physicians to get the financial and technical resources they need to strengthen the primary care they provide, the payers to reduce their costs through better coordinated and data-driven care, and the patients to enjoy the outcomes of better access and better care.

“Ultimately it comes down to patient-centered care,” said Dr. Kyu Rhee, vice president of integrated health services at IBM. “It is important to give physicians and their teams the tools, data and analytics to better integrate and coordinate care and improve the healing relationship between patients and their doctors. Such multi-stakeholders are essential. Payers must be involved if we are to achieve care that is continuous and collaborative.”

Primary-care practices which enroll in the five-point program must agree to provide a range of enhanced services for their patients. They will offer longer and more flexible hours using electronic health records. They will deliver preventive care. They will take the responsibility of coordinating care with patients’ other health care providers (“coordinating care across the medical neighborhood”). They will engage patients and caregivers in managing their own care. And they will promise to provide individualized, enhanced care for patients living with multiple chronic diseases and higher needs.

Innovative financial carrots for participating physicians will include a monthly care-management fee on behalf of their fee-for-service Medicare beneficiaries and after the first year of the initiative the potential to share in savings to the Medicare program. Practices will also receive compensation from other payers participating in the initiative, including private insurance companies and other health plans, which will allow them to integrate multi-payer funding streams to strengthen their capacity for quality improvement.

Point of contact

Why this focus on primary care? “A primary-care practice is a key point of contact for patients’ health care needs,” explained the website of the federal Center for Medicare and Medicaid Innovation. “In recent years, new ways have emerged to strengthen primary care by improving care coordination, making it easier for clinicians to work together, and helping clinicians spend more time with their patients. All around the country, healthcare providers and health plans have taken the lead in investing in primary care. Employers across the country have found that with health coverage policies that emphasize primary care, coordinated care, and other strategies that keep their employees healthy, they not only support a healthier workforce, they create a healthier bottom line.”

The seven pilot markets chosen for the Comprehensive Primary Care (CPCi) initiative include four entire states — Arkansas, Colorado, New Jersey and Oregon — and three regions: the Hudson Valley, Cincinnati-Dayton in Ohio and Kentucky, and greater Tulsa in Oklahoma.

Why was the Hudson Valley chosen? Fishkill-based Thinc (Taconic Health Information Network and Community) is probably one of the reasons. The Hudson Valley’s premier health information technology think tank, Thinc’s primary purpose has been “to advance the use of health information technology through sponsorship of a secure health information exchange network, the adoption and use of interoperable electronic health records, and the implementation of health improvement activities.”

In pushing toward these goals, Thinc’s training activities have provided the Hudson Valley one of the most technologically linked population of primary-care providers in the nation. The organization has explored quality improvement initiatives that include public health surveillance and reporting, pay for performance, patient-centered medical-home-practice transformation, care-coordination activities and public reporting.

Thinc has also been working for several years to strengthen multi-stakeholder collaboration. These years of preparation are finally about to lead to a new level of cooperation. The new announcement from Washington confirms the willingness of the payers to provide innovative primary-care physicians with the tools they need to be the central building block of a more rational health care system.

A full plate of ‘clinical integration’

(L-R) HealthAlliance chief strategy officer Josh Ratner, CEO Dave Lundquist and chief information officer John Finch.

As it struggles with complex survival issues, HealthAlliance of the Hudson Valley, the Kingston-based integrated health-care system, is trying to strengthen its relationships with Ulster County’s physicians. According to its chief strategy officer, Josh Ratner, HealthAlliance has recently reached out to about 60 primary-care physicians in approximately 30 practices to discuss closer ties. Ratner and other HealthAlliance executives met about two weeks ago with the primary-care providers as a group. Ratner said the session was positive and supportive.

The closer ties being discussed are part of a movement to reduce costs and improve quality through coordinated care across the fragmented national health system’s different functions, activities and operating units. The term “clinical integration” has been increasingly used to describe such coordination of care.

Clinical integration is getting a boost from the recently enacted federal health care reform laws, which include support for pilot integration projects and some partial regulatory relief. According to the American Hospital Association, several provisions in the law may help overcome some barriers to integration.

“It’s something we may want to be part of,” said Ratner.

As HealthAlliance moves forward, there’s ample evidence that delays in efforts at integration may not be option. “Clinical integration has vaulted from good idea to a business imperative, thanks in large part to the new health-reform law,” said one recent article in a national health-management magazine.

The combination of Benedictine and Kingston hospitals, under pressure from the state Berger Commission, was a big step in reforming the fragmented local system of health care. The merger and subsequent reorganizations created a smoother, better integrated continuum of care. But dealing with the distractions caused by the consolidation seems to have taken attention away from the urgency of clinical integration. So now HealthAlliance must play catch-up at an awkward time.

 

Ulster County has been a stronghold of highly independent practitioners of primary care. In an age where the costs of health care are under constant attack, however, Ratner thinks that major change is inevitable — no less for the beleaguered hospitals than for the primary-care providers. As well as helping steady HealthAlliance’s business, a more closely integrated system may offer the most promise in maintaining as much treasured physician independence as can be preserved. “It would be a feather in our caps if we got the docs to work together in a unified way,” Ratner said.

Right now, CEO Dave Lundquist and his management team at HealthAlliance could use a few new feathers in their cap. HealthAlliance’s strategy for creating a coordinated health-care delivery system with the potential to grow into a regional center for excellence has run into economic problems whose severity had been unanticipated. Those who objected to the merger see the dire alternatives presently facing the HealthAlliance administration as vindication of the correctness of their own earlier gloomy predictions. And many of those who supported the merger are appalled by the probability that one of the hospitals could be closed. Success has many fathers, and failure is indeed an orphan.

“The institutions should have been braced for the economic challenges they ultimately faced,” said a press release this past week from Assemblyman Kevin Cahill, who had been instrumental in getting $47.5 million in state support for the creation of HealthAlliance. “I have already heard from many corners that the exclusion of the public from discussions thus far of restructuring the organization is disconcerting and frustrating.”

Cahill expressed concern. “The merger, in theory, should have brought us closer to a coordinated health care delivery system with the potential to grow into a regional center for excellence,” said Cahill.

HealthAlliance’s economic problems come at a time when it needs all the financial resources and management skills it can muster. Its strategy in adopting change after earlier innovators have ironed out the kinks — as chief information officer John Finch puts it, “the second mouse gets the cheese” — is now suspect. The situation is exacerbated by the fact that competing hospitals with direct physician employment already have considerable experience with clinical integration. The form of clinical network model now being proposed by HealthAlliance would take time to build, test and integrate.

The quest to accelerate the pace of operational change through integrating physician-hospital information systems and streamlining administrative processes increases the potential for the delivery of high-quality health care. That unquestionably makes it a move in the right direction. But the road that must be traveled is a long one. In a challenged managerial environment, the execution of the strategy is unlikely to come easily.