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.

Audacious goal

Dr. La Mar Hasbrouck. (photo by Dan Barton)

Last Friday was La Mar Hasbrouck’s last day of work in Ulster County. He had been serving as the county government’s combined health director and commissioner of mental health. His departure from the job, the highest-paying in the Ulster County budget, came 11 days after the announcement was made that he had been appointed director for public health for the State of Illinois.

In his statement, Ulster County Executive Mike Hein had put a positive spin to the considerably greater responsibilities Hasbrouck was taking on in his new job. “I think it’s a testament to Dr. Hasbrouck and his talents as well as the reforms he put in place in Ulster County,” Hein’s press release said, “that an organization the size of the State of Illinois has selected Dr. Hasbrouck to be their director of public health.”

The job was not left vacant for long. On Tuesday Hein appointed Dr. Carol Smith, medical director for urgent care providers Emergency One, as head of the two departments. Smith, whose position is subject to county legislative approval, will serve on an interim basis starting May 7. Smith, 58, is board-certified in internal medicine and is completing a master’s degree in public health.

Illinois’ population is close to 12 million, about 75 times that of Ulster County. In their announcements, none of the Illinois news organizations Googled referred to Ulster County as the location where the state’s new health director had served. They instead followed the formulation established in Gov. Pat Quinn’s press release that the new guy had been health director “in upstate New York.”

Two and a half years ago, Hasbrouck, now 44, had succeeded Dean Palen, who was fired by Hein from his Ulster County job under cloudy circumstances. Last year Hasbrouck became mental health commissioner as well. His initiatives included the development of a prevention-based health agenda, the establishment of a stakeholder-inclusive process, and the securing of hundreds of thousands of dollars of outside grants to increase local services.

In the public eye, Hasbrouck might have been most noticed for his involvement in the Healthy Ulster initiative that Hein had proclaimed, an effort whose long-term goal was to make Ulster the healthiest county in New York State. The University of Wisconsin’s Population Health Institute keeps county data, based on a potpourri of 13 extremely varied indicators for all the counties in every state, and in the past three years has published the rankings on its website.

In 2010, Ulster ranked 33rd out of the 62 counties in New York State. In 2011, it ranked 35th. The statistics for 2012, just published on April 4, show Ulster County as ranking 29th among counties in the state.

Healthy Ulster County Week this year runs from May 19 to May 28.

Nearing the end of his last day of work, Hasbrouck predicted that Ulster would rise further in the rankings as the improved efforts of the organization that had been established would bear fruit. “You’ll see a turning of the tides as we lower the risk factors and establish beachheads in the areas we want to improve,” he said.

Hasbrouck’s view was that Ulster County now had the framework, the energy and the political will for continued improvements in public health. His role, he said, had been “to breathe life into the framework and to galvanize the community” to support the department’s efforts. The operational framework was now in place. “It takes a community,” he said. “I’ve been enriched by the partnerships we’ve made.”

What qualities and ambitions did he think his successor in the position should have?

First, he said, with the county public health framework now in place it was not necessary “to re-create the wheel.”

Secondly, it was important to continue and to grow the partnerships the department had worked hard to enrich.

And finally, he suggested, “Try to get a visionary, because we have a pretty audacious goal.”

A unified medical staff

They’re called “mirror committees.” As of February, members of the medical staffs of Benedictine and Kingston hospitals are meeting to make decisions for one hospital. After they adjourn that meeting, the same staff immediately holds a meeting to make the identical decision for the other hospital.

Strange but true. According to the state-sponsored agreement that brought the Kingston hospitals under the same administrative umbrella three years ago, Benedictine and Kingston hospitals aren’t allowed to merge their medical staffs. Nevertheless, a couple of months ago they elected a first-ever unified set of medical officers and physician department heads.

According to anesthesiologist Dr. Martin Cascio, an ex-officio member of the HealthAlliance board of directors and now the first president of the unified medical staff, the medical staffs of the two hospitals meeting separately proved an increasingly cumbersome and repetitious arrangement, with many of the same participants in both meetings.

Doctors are busy people. “We had so many meetings in the past couple of years,” reported Cascio. “It was a waste of everyone’s time.”

In his unpaid but lofty position, Cascio acts as liaison to the medical staff. His job is to get feedback from the staff and to incorporate the staff in HealthAlliance strategies for encouraging best practices. “If you can get the feeling of team,” he said, “everyone buys in and feels validated.”

Cascio sometimes has mixed emotions about his administrative responsibilities. “It’s great,” he said, “but it’s really hard.” He likened the job of leading doctors to herding cats.

The other new officers include doctors Mark Josefski (vice president), Fabio Danisi (secretary) and Richard McNally (treasurer).

HealthAlliance of the Hudson Valley’s CEO Dave Lundquist expressed support for the new arrangements in a press release. “We applaud and support the efforts of our physicians to work effectively together in providing the physician leadership necessary to establish excellence in our health-care services,” he said.

Dr. Frank Ehrlich, chief medical officer for HealthAlliance, was similarly positive, calling the unified structure “an enormous boon” both to medical functionality and to the interface between administration and physicians. “We have two sets of customers,” said Ehrlich about HealthAlliance, “patients and doctors.” As the only physician on the organization’s executive team, Ehrlich often communicates with Cascio and other members of the doctors’ executive committee.

HealthAlliance is in the beginning steps of creating clinical integration, which can be defined as a connected community of health-care providers sharing patient information, streamlining administration, and increasing the potential for high-quality heath care. The goal is often associated with the increased sharing of computer information in various locations through a secure web portal.

Best practice

Meanwhile, the department heads at HealthAlliance are striving to build and follow best practices within their departments, striving to achieve ever-higher standards of patient care.

“It’s like following a checklist. Sometimes following a checklist doesn’t go well with original thinkers,” conceded Cascio. But studies have shown that repetition of details constitutes the core of best practice. He compared the job of a doctor to that of a pilot: It’s often not good enough to be right 99 percent of the time, he said.

Building a high-quality medical staff, said Cascio, begins with a focus on improving quality. That’s accomplished among other ways by careful attention to recruitment and credentialing. There are two paths leading to the provision of new medical services at HealthAlliance. In some cases, the administration sees an opportunity and reaches out to the medical staff to explore it. In others, physicians discuss opportunities they see with Cascio and other medical staff.

In one example, Cascio worked with Orthopedic Associates of Dutchess County in another institution. This relationship helped lead to one between Orthopedic Associates and the administration of HealthAlliance. A contract was negotiated by which the Dutchess-based partnership would provide on-call emergency orthopedic services in Kingston. Orthopedic Associates, whose website lists 26 physicians, is now occupying a renovated facility on Ulster Avenue, and performs a lot of surgery in Kingston.

Eleven medical department heads were selected at HealthAlliance in February. Fareed Fareed is head of the emergency department, John Anderson is head of family practice. Donald Louie is chair for anesthesiology, Joseph Christiana for internal medicine, Bruce Moor for radiology, and Gerald Kufner for neurosciences. Dominique Delma is chair for obstetrics and gynecology, Casey Rosen-Carole for pediatrics, Richard McNally for pathology, and Carlos Valle for psychiatry. Stephen Maurer and Darren Rohan are co-chairs for surgery.

Dr. Cascio signed contracts to provide anesthesiological services for both hospitals separately back in 1997, when he moved to Rhinebeck. He has served on the executive committee at Benedictine Hospital and was vice-chair of medical staff there.

No time to lose

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Mark Bedell, Town of Shandaken EMS, sits with a Lifenet wireless device in an ambulance.
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Door-to-balloon time (D2B) makes the difference between death and survival from a heart attack.

There are two kinds of heart attacks: one in which an artery to the heart is partially blocked, and the other in which an artery is completely blocked. The second kind, of course, is more imminently life-threatening. Time becomes of the essence. If medical personnel can get a balloon-tipped tube to open the artery up quickly, the data shows, the patient stands a good chance of survival.

To speed up the process, local ambulances have recently been equipped with Lifenet systems that enable paramedics to hook up a heart-attack patient to an electrocardiogram (ECG) monitor and transmit the readings directly to the hospital through the Internet. Physicians can make decisions about the patient’s care while the ambulance is en route, so hospital staff can be ready to leap into action upon the patient’s arrival. Based on the ECG, paramedics can also get advice from doctors about interim treatment while the patient is still on the way to the hospital.

The American Heart Association estimates that close to 400,000 people a year in the U.S. experience the more serious type of heart attack, known as STEMI (ST-segment elevation myocardial infarction). Part of an ECG reading is the ST-segment, which is elevated in situations where a coronary artery is fully blocked. The ECG is a critical part of diagnosis, and paramedics are trained in its use.

Studies show that patient outcomes significantly improve and hospital stays are shorter (Journal of the American College of Cardiology, 2006) when door-to-balloon time is 90 minutes or less. Local emergency crews are just beginning to use the Lifenet system to pare down their D2B time.

The system was purchased by HealthAlliance of the Hudson Valley through a grant from the federal government’s Hospital Emergency Preparedness Program at a cost of $49,025, explained Richard Parrish, EMS coordinator at HealthAlliance. The Lifenet system includes a base receiving station in the Kingston Hospital emergency room and modems for the Ulster County’s six ambulance services, Woodstock Rescue, Shandaken Ambulance, New Paltz Rescue, Ellenville Rescue, Mobile Life Support Services, and Diaz Ambulance.

Transmission of ECG data requires cell service, which is not yet active in Shandaken. At the February 6 Shandaken town board meeting, the town’s ambulance service administrator, captain Richard W. Muellerleile, asked that residents notify the service if they own a Verizon network extender, which enables connection to cell service. Ambulance staff hopes to compile a confidential list of extender locations so they can get information from the cardiac monitor while still in the ambulance instead of waiting until they reach wireless network access closer to Kingston.

A network extender plugs into an existing high-speed Internet connection to communicate with the wireless network. The various brands listed on Amazon.com are priced between $100 and $200.

Kingston Hospital is among the quarter of hospitals in the United States equipped to treat patients with percutaneous coronary intervention (PCI), the preferred type of treatment for STEMI, according to the American Heart Association. PCI is a group of medical procedures that use a mechanical means to treat patients with partially or completely restricted blood flow through an artery of the heart.

Balloon angioplasty, for example, involves insertion of a tube into an artery in the groin. The tube is threaded to a trouble spot in the coronary artery, where a balloon attached to the tip of the tube is then inflated, compressing the blockage and widening the artery to restore blood flow to the heart muscle.

Another PCI procedure involves use of a stent, a wire mesh tube that is inserted to open an artery and prevent re-blockage.

A catheterization lab at Kingston Hospital enables staff to perform cardiac catheterization, a procedure to examine blood flow to the heart and test how well the heart is pumping.