The Mihalik Blog

Making Practitioner Performance Data Public

It’s not really news that many stakeholders in the health care field are trying to make outcome data for individual practitioners publicly available.  What I think IS news is NCQA’s entry into the field.  This event—and its potential impact—may have slipped by with little fanfare.

NCQA, of course, is the organization that accredits the majority of US health plans (some two-thirds of the nation’s 450 health plans at last count).  NCQA standards for Physician and Hospital Quality (PHQ) that are currently voluntary.  Accredited health plans can choose to undergo a PHQ survey and, if successful, earn a distinction that separates them from other plans. 

The PHQ standards are part of NCQA’s Quality Plus program.  Other components of Quality Plus have gone from being voluntary to being a mandatory part of the health plan accreditation process.  The same may well happen to PHQ.

The whole point of the PHQ standards is to encourage health plans to measure outcomes and cost for individual physicians and hospitals and to make the data public.  Outcome and cost data for individual practitioners and hospitals, collected and made public by a health plan, and presented in a manner that facilitates side-by-side comparison is intended to provide a basis for individuals to select providers based on quality and value, not just cost. 

With NCQA’s market dominance, this move could have a significant impact on physicians and hospitals that may begin to see changes in patient volume.  At the very least it may prompt discussions with patients who want to better understand what the data mean. 

100% Club—Twice Over

Well, the great folks at Community Care Behavioral Health Organization in Pittsburgh, Pennsylvania have succeeded in garnering a perfect score from NCQA on their most recent MBHO accreditation.  This is the second time in a row that Community Care has achieved this distinction. 

With this milestone, Community Care has joined an elite club, with the only other organization to have achieved the same honor—University of Miami Behavioral Health.

I am honored to have had the ability to work closely with these two outstanding organizations and look forward to making it three in a row!

Advance Directives: Theory and Practice

Many of you know my business partner, Melinda Orlando.  Today’s column is one that she wrote based on personal experience. 

Joint Commission standards require hospitals to address the wishes of patients regarding end of life decisions.  Whether or not the patient has signed an advance directive must be documented in the medical record and staff must honor advance directives within limits of the law. 

Advance directives have been widely published in popular literature but may not be in common use with the very elderly population.  Mom, however, established an advance directive many yeas ago—long before she reached 93 and broke her hip.  Having observed a dear friend on life-support for a long time in a totally non-responsive state prompted her to make clear to all who would listen that this was not to be her end.  Under threat of life-long harassment from the other side, she informed her three children of her wishes, signed all of the forms, and distributed a copy of each of us. 

Prior to her recent surgery for hip pinning (the first hospitalization in 40 years), she discussed her wishes with her physicians.  In the presence of her children and husband of 69 years, she assured the surgeon and anesthesiologist that should they need to honor her advance directive, she would remember them kindly as having done the best possible to help her.  She talked about how difficult it might be to make this decision and that she trusted them and her family to do the right thing—what she wanted.  No doubt this was all adequately documented in the electronic medical record that was in use near the bedside.  Respecting patient preferences is dependent upon appropriate documentation being readily available to staff when it is needed. 

Surgery went well.  However, about an hour into recovery Mom’s blood pressure dropped and cardiac symptoms developed.  One of the best things about receiving care in a large teaching hospital is the range of staff available, from medical students to the attending physician.  This brings a variety of ideas and choices.  The down side is the eagerness to act aggressively.  Thus, we encountered a well-intended resident who insisted we proceed immediately to cardiac cath to locate and correct a possible blockage. 

Although this very type of circumstance and intervention had been discussed and rejected by Mom in this resident’s presence, he wanted to “save her life.”  The attending physician was called.  He ordered medications to maintain comfort, and observation, according to her wishes.  Mom recovered and is walking well with a walker and without evident heart problems.   

The moral of the story (from the patient’s perspective) is to have an advance directive.  Be sure and discuss your wishes with all immediate family members and with all caregivers.  It is helpful if caregivers, particularly physicians, really understand your position and get to know your feelings and beliefs; not just that you have an advance directive.  The better they understand what an advance directive means to you, the better they will be in carrying out your wishes.  It is also important to have an advocate with you at the hospital if you are not fully alert or able to express your wishes.  This is especially true following surgery when you may not be able to express yourself. 

The moral of the story (from the facility’s perspective) is to develop a system of checks and balances to be sure that caregivers follow a patient’s advance directives.  If they are not willing to do so, they should be upfront with the patient and family about their position in order to provide the opportunity for another caregiver to be chosen.  Frequent education and training on advance directives and ethical issues in care is critical for improving and maintaining staff knowledge and performance in this important area.

Melinda Orlando

Education on Accreditation Standards

I know I spend a lot of time talking about standards compliance in this column.  I’m still figuring out what the best mix of topics is.  Since (I assume) most of my readers are interested in standards compliance this is where I’ve been focusing.  If you’re interested in other topics please let me know.  I’d be excited to get my first bit of on-line feedback on the blog.

In the few paragraphs that I have for each entry I can’t do much except provide a pin-point view of a particular topic or a personal perspective on a larger issue.  Face to face educational programs are a forum where I can deal with a topic in much more depth. 

In addition to offering customized educational programs through The Mihalik Group and serving as a member of our speakers’ bureau, I teach seminars for NCQA and provide education and training in a number of other venues.  I thought I’d use this column to note a few of the seminars that I’ll be involved in teaching. 

On September 20, 2007 I’ll be teaching NCQA’s seminar on Physician and Hospital Quality in Arlington, Virginia.  The PHQ standards are still a voluntary add-on component for an MCO survey.  These standards focus on an MCO’s efforts to make performance data on physicians and hospitals available for members.   

I’ll be doing a repeat performance of the seminar on Physician and Hospital Quality in Phoenix on October 18, 2007.  On October 19, 2007, also in Phoenix, I’ll be co-teaching a program on Quality Plus Challenges and Solutions.  This program focuses on the former Care Management and Health Improvement standards that were integrated into the 2008 MCO standards as the new Member Connections category, expanded Disease Management requirements, and a new standard on Complex Case Management. 

NCQA’s Introduction to NCQA Accreditation for MCOs, PPOs and MBHOs, which I’ll be co-presenting on November 5-6, 2007 in Washington, DC is targeted to staff who are new to accreditation and to organizations thinking about their first accreditation survey.   

I would enjoy seeing you at one of these programs. 

If you’re interested in a presentation for your organization contact The Mihalik Group.

On the Road Again…

I’m writing this at the end of a long stretch of work-related travel on my one day in the office before I leave again on more travel—this time for pleasure.  It therefore seems natural that I’m sitting here reflecting on what it’s like to be a consultant as I’m preparing for multiple transitions. 

While studying for my graduate degree in Anthropology, I read often about re-entry—the experience of coming back to one’s home (and usually one’s country) after doing fieldwork—and how difficult the process can be.  I even got to experience it a few times; like when I returned after studying religious cults in Guyana and managing a psychiatric unit at the public hospital in Georgetown, the capital.  I didn’t really think about re-entry applying to my work as a consultant.  It applies but it’s tough to remember.

For me—and I guess for most people who travel frequently for work—the experience is a continuous one.  I’m in the office one day, on the road for a while, suddenly back at home, and then off to the office (maybe) before hitting the road again.  Each day just rolls into the next, a continuous experience.

But for the people in the office and at home, I’m GONE!  When I come back I pick up where I left off (or so it seems to me) but in my absence everyone else has moved on a bit.  Their experience is a continuous one, too.  It’s just that my presence in it is discontinuous. 

Not only do I have to slot myself into the flow without disrupting it, but I need to adjust roles as well.  As I’ve gotten reminded all too often when returning home from a long stretch of travel, I’m not the expert any more.   My opinion has somewhat less weight with the folks at home than it does with my clients.  Go figure…

It’s a tribute to the wonderful people who support me in the office and at home that I can manage all this travel.  I come back after variable periods of being away (from days to weeks) and everything is running smoothly.  I don’t face crises that have been festering in my absence.  Everything is just ticking along.  It’s difficult to manage but somehow these incredible people do it!

It usually takes me a day to acclimate and catch up when I get back.  Even though I try to keep up with email and phone messages, there are always those things that can’t be resolved while away.  So, the first day back is usually dedicated to catching up.  I guess that relates to why I’m reflecting on my life as a consultant today—I’m facing multiple exits and entries in just over 24 hours.  I got back late last evening, after the all-too-predictable flight delay, and re-entered my personal life (catching up on relationships, mail, and home cooking).  Today is my re-entry day in the office but no sooner will I catch up than I leave again on vacation (tomorrow morning)—yet another exit and entry. 

It’s interesting that when I sat down to write this, I thought I’d write about the experience of consulting—not the experience of traveling to be a consultant.  I guess that’ll have to wait for another entry. 

Health Risk Assessments

The 2007 NCQA standards are now officially in effect.  In a recent column I discussed some of the more significant changes for 2007. 

I know that many organizations still have work to do to come into full compliance with these challenging standards.  The web-based requirements for MCOs seem to be presenting the most challenges. 

Luckily, NCQA has decided that outsourcing many of the web-based components of the Member Connections standards does not trigger the delegation oversight process.  This is great news since most organizations are using vendors for many or all of these functions. 

Although Health Risk Assessments can be outsourced (and usually are), there are a few factors that an MCO won’t want to leave solely in the hands of a vendor.  These are MEM 1A.4 and MEM 1E.

MEM 1A.4 requires that the organization describe how the information obtained from the HRA will be used and to whom it will be disclosed.  This statement should be one that each organization customizes.  Default text crafted by the HRA vendor is not likely to adequately describe the specific disclosure processes for individual MCOs.

MEM 1E focuses on follow-up resources presented to a user of the HRA.  The resources should be related to the risk factors identified in the HRA.  Although resources can be print materials, the MCO would have already presented on-line educational interventions as required by MEM 1D so printed material may not be appropriate.  The resources, as intended by MEM 1E, include things like support groups, health club memberships, classes, and so forth.  While some of these resources can be national, and thus identified by the HRA vendor, many of them will be local and must be identified by the MCO. 

Resources must be identified for each of the factors identified in MEM 1E and suggested to members, as appropriate, based on the results of the HRA.  The factors for which resources must be identified are:  eating right, smoking cessation, lowering blood pressure, lowering cholesterol, driving safely, keeping physically active, safe use of alcohol, handling stress, maintaining mental health, and avoiding substance abuse.

Using a vendor can certainly ease the implementation of an HRA, but not everything can be left to the HRA vendor. 

If you need assistance understanding, or implementing, the NCQA standards we’re here to help.

Disease Management Zeitgeist

When I was in graduate school (more years ago that I care to think about) pursuing a degree in anthropology I remember reading an article suggesting that novel ideas were really the product of their time.  We associate certain ideas or breakthroughs with specific people because they’re the ones who managed to make the idea public, but if they hadn’t done so someone else would have, as the theory went.  Interesting thought…

Behavioral health disease management programs are the current wave, especially those focused on depression.  I’m actively working with three companies right now to develop behavioral health disease management programs.  There’s clearly a groundswell of interest in such activities. 

Behavioral health disease management programs aren’t new.  Over the last ten years I’ve been involved in developing several, for both managed care organizations and for pharmaceutical manufacturers.  But three at one time is a new record.

To be sure, there are concerns about behavioral health being different from non-behavioral health.  Confidentiality and stigma are two of the often cited concerns.  Organizations are concerned about contacting a member and suggesting or acknowledging that the member might have a behavioral health disorder.

While I understand the need for sensitivity, my experience with sending out patient education materials on depression, attention-deficit hyperactivity disorder, and postpartum depression for the past eight years tells me this is not as significant a concern as many people think.  Educational materials that The Mihalik Group has developed on these topics have been sent to thousands of individuals.  Often we manage the entire process from doing the mailing to collecting feedback from members on the usefulness of the materials.  Only a few percent of members ask to be dropped from the rolls of the program—without much of a fuss.

Practitioner support is another key element to program success.  When a practitioner knows how a health plan will interact with his or her patients, anxiety goes way down and support for the program goes way up.  Sending a complete set of program materials to practitioners along with easy to understand information about how the program works (possibly formatted as a set of FAQs) has been successful for us.  In some instances practitioners have been so positive about the materials, and health plans so happy that the practitioners like the materials, that they have purchased additional sets to give to practitioners for distribution to patients who are not health plan members. 

This is a great time to be thinking about behavioral health disease management programs.  With the importance of HEDIS results for accreditation status increasing each year, and the difficulty in getting the behavioral health HEDIS results to move, effective interventions to positively affect behavioral health HEDIS can be a differentiating factor for health plans.  There’s still time to be ahead of the curve.  Although behavioral health HEDIS results have been stagnant for quite a while, that is likely to change with health plans focusing their efforts in this direction.