It is an unfortunate truth that many of those who are most in need of affordable healthcare are the least likely to be able to afford it. According to a study  by the Henry J. Kaiser Family Foundation, most of the 46 million uninsured people in this country do not have access to employer-sponsored insurance. About two-thirds have incomes below 200 percent of the federal poverty level (about $44,050 for a family of four in 2008). Every year about one-quarter go without needed care for which they cannot pay and are also less likely to receive preventive care and services for major problems, creating even more serious health problems for many.

When these un- or under-insured people do seek care, they often face unaffordable medical bills with out-of-pocket costs comprising one-third of their care. And they are often charged more for care than those who are insured, a burden compounded by low to moderate incomes and few, if any, savings.

We should all be grateful to Dr. Renee Hsia (pronounced “Shaw”) of UCLA-San Francisco Emergency Medicine for using a personal relationship as a springboard to exposing the consequences that can derive from this situation.

Alerted to the cost of an emergency appendectomy when a friend underwent the procedure, Dr. Hsia and her co-investigators studied the records of nearly 20,000 patients in California who were hospitalized for acute but uncomplicated appendicitis in 2009. The first surprise was that the cost for the procedure ranged from a low of $1,529 to a high of—hold on!—$182,955. The median cost was $33,611, and you don’t need me to tell you that even that amount could come as a catastrophic cost to a patient with little or no insurance.

The second and less savory surprise was that charges were higher for Medicaid patients and the uninsured, as well as for older patients.

In the United States today, healthcare is often positioned as a commodity that can be governed by the rules of the marketplace. For this to work, it is necessary that both patients and care providers have a “reasonable sense” of what the product costs. Providers often do not know what the services they recommend cost, and patients with viable medical insurance are usually immune to these charges. The underinsured or uninsured, however, see “staggeringly high numbers” without knowing what they mean or if they are appropriate.

Some two-thirds of bankruptcies in the United States are due to catastrophic medical costs, so making the patient an educated consumer who can make educated choices must be a major part of any healthcare reform. The point at which these two studies intersect, i.e., when those who are least able to pay are charged the most, should be a red flag for anyone who is concerned about our society’s ability to access adequate healthcare without courting financial catastrophe.

I encourage you to read Dr. Hsia’s full report at http://archinte.ama-assn.org/cgi/content/short/archinternmed.2012.1173. Registration is required.

This two-part Conversation is with officers of Mayo Clinic, which for more than 100 years has made the best interests of the patient the guiding principle of healthcare delivery. Mayo Clinic received the organizational Picker Award for Excellence® in the Advancement of Patient-Centered Care in 2011.

A Conversation with Mayo Clinic (Part 1)

Mayo Clinic has a tradition of patient-centered care that goes back for more than a century. How do you keep such a tradition fresh and new?

John H. Noseworthy, M.D., President and CEO, Mayo Clinic Board of Trustees: We are always considering how we can strengthen and perpetuate Mayo Clinic and keep the best interests of the patient at the center of any conversation about our future. The Mayo brothers had a vision that grew from our roots in frontier medicine to a multi-site medical organization serving one million patients annually. More recently, we envisioned becoming a premier academic medical center. We feel that we’ve realized that vision. Now, in keeping with the Mayo brothers’ tradition of patient-centered care, we have a new vision: to carry the candle of medical science into a future they once only imagined.

While we’re investing to secure our place as a destination center, we’re also investing to secure our place in the marketplace as creators of new health delivery models, and moving fee-for-service payments to a diversified revenue stream—not to mention lifelong relationships with people, regardless of their location. All of this will help create Mayo’s future state, which will be able to withstand outside pressures from many angles.

Over so long period of time, it would seem that Mayo had covered all the patient-centered care bases by now. Where do you look for new challenges?

JHN: We don’t have to go looking for them; a rapidly changing economic environment presents us with those challenges. Changes in the business of healthcare—payer and provider consolidation, insurance reform and the like—require us to discover new ways to keep the needs of the patient first. We’re reaching out to patients in several new ways, including our Mayo Clinic Care Network, which integrates and standardizes relationships we’ve had with other providers for many years in order to allow folks to receive healthcare closer to home.

If we are to remain the right choice for our patients, to remain trusted and affordable in this environment, we must extend our reach. If we fundamentally believe that we offer an unparalleled patient experience, we can share what we know through an affiliated physician using AskMayoExpert to help confirm a diagnosis, or perhaps through a person looking up information on his hypertension on Mayoclinic.org. We’re not taking away our vision of being a premier academic medical center; we’re expanding that vision beyond our front doors in Rochester, Jacksonville and Scottsdale.

We started as a small country practice in Minnesota. We’re now a vast medical complex that treats a million people each year and has revenues of $8 billion and employs 58,000 people. We are now writing the next chapter in the story, and I’m excited to see what the next years will bring.

When you find a new aspect of patient-centered care, how do you integrate it into your existing structure?

Charles M. Harper, M.D., Executive Dean for Clinical Practice: Our goal at Mayo is to give patients an unparalleled healthcare experience by building a single, integrated, high-value practice across all of Mayo Clinic, including all sites, departments, specialty service lines and care delivery platforms (i.e., hospital, outpatient and eHealth). Our single strategic and operating plan is helping us drive convergence, appropriate standardization and integration. Building this single practice allows us to integrate changes across the enterprise while preserving and enhancing the fundamental values and principles of Mayo Clinic, including those defined in the Mayo Model of Care. Some of these principles include patient-centered compassionate care; a leadership model that places high value on the physician-administrator partnership; clinical teamwork and integration; quality, trust and respect;  innovation, engineering and advanced technology; and a humanitarian societal commitment.

Part of the patient-centered care tradition at Mayo is that it includes every member of the staff from CEO to parking attendant. How do you reach everyone with a new patient-centered care idea or protocol?

Shirley A. Weis, Vice President and Chief Administrative Officer: We haven’t changed our primary value since we were founded. When people apply to work at Mayo Clinic, they know that the needs of the patient come first. That’s such an integral part of our culture that even members of our staff who may never physically touch a patient believe strongly that what they do provides patient-centered care. Anything relevant to the patient is relevant to all of us at Mayo.

We are really focused on transparent communication of our strategies to all our employees. I meet with the entire staff in person to talk about our strategy and new updates to our practice. Drs. Noseworthy and Harper also meet with staff, and we empower our management to carry the candle of patient-centered care to their employees, whether they’re nurses or computer programmers.

How do you measure the success of patient-centered care at Mayo?

CMH: We use a basket of proven improvement techniques to define, measure, analyze, improve and control processes that are key to the success of our patient-centered care. We have also developed a unique construct designed to improve the rate and effectiveness of the spread of best practices.

Mayo conducts surveys in both outpatient and inpatient environments and compares performance to national, state and local benchmarks. We pay close attention to former and current patients’ willingness to recommend Mayo to family/friends as a sign that we’re doing our job well. And of course, we continuously monitor a variety of national benchmarks.

Under Maine state law, all patients whose care providers participate in the HIE must be notified that they have been entered into the system on their first visit after the care provider has joined. They must also be provided with a state-approved opt-out form. In addition, patients may review with the care provider the information that has been entered and ask that any errors be corrected. HealthInfoNet is working to upgrade the program so that these and other functions can be performed online by the patients themselves.

Access to a patient’s electronic health record has undoubted benefits. But patients who are so enrolled should:

1. ask if their care providers participate in the system;
2. decide whether they want to be included in the system; and if they do,
3. review their records to make sure they do not include any errors.

For more information, visit HealthInfoNet at www.hinfonet.org.

Shortly after Harvey’s death, Susan Frampton and Sara Guastello of Planetree, an organization of which Harvey thought very highly and to which he contributed many of the resources mentioned above, wrote a profile of Harvey, whom they describe as a pioneer of compassionate healthcare.

We at Picker Institute cherish these words from our friends at Planetree, and we think it is appropriate to revisit them at this time.

Click here for the profile of Harvey Picker.

Lisa M. Letourneau

One of the ways Picker Institute supports patient-centered care is by recognizing significant contributions to achieving patient-centered care state- and/or nationwide. “Conversations with Leaders in the Field of Patient-Centered Care” is a regular feature that highlights these contributions.

This Conversation is with  Lisa M. Letourneau, MD, MPH, the executive director of Maine Quality Counts,a regional healthcare collaborative formed in 2003 and committed to improving health and healthcare for the people of Maine. QC works with a broad group of stakeholders to coordinate efforts to advance local, patient-centered care and the resources that support it. QC’s goals are to improve health, promote consistent delivery of high-quality care, improve access to care and contain healthcare costs.

What led to the formation of QC in 2003? How would you characterize the growth of the agency since then?
Maine Quality Counts (QC) started in the fall of 2003 when it was recognized that many providers and organizations in the state were beginning to take steps to improve chronic illness care, and that there would be real benefit to sharing this learning. This was a short time after the publication of the Institute of Medicine’s “Crossing the Quality Chasm” report, and around the time that Dr. Ed Wagner and his colleagues at the MacColl Institute (Group Health) had developed the “Chronic Care Model” as a synthesis of best practices for improving chronic-illness care. Driven by this shared recognition and belief in the value of promoting a systems approach to improving chronic care, Dr. Karen Bell (at that time, medical director of Blue Cross Blue Shield of Maine) and I (at that time working for MaineHealth) brought together a diverse group of stakeholders with a plan to convene a statewide conference to communicate the growing business case for changing systems of healthcare, and to expand on successful efforts to date to improve chronic care.

We convened a multi-stakeholder advisory group to hold a series of statewide conferences on chronic illness care. We aimed to use the conferences to familiarize stakeholders with the elements of the Chronic Care Model, including the business case for quality, and to show how Maine healthcare providers had successfully implemented the model to improve outcomes. We wanted to demonstrate how systemic change was improving care in Maine primary care practices, and to make the case that all stakeholders needed to take an active role to improve healthcare quality and costs in Maine. We felt that we needed to do more to forge collaborative relationships among providers, employers and payors to speed broader adoption and support sustainability of the Chronic Care Model.

The Quality Counts, Part 1, conference was held in December 2003, with close to 200 attendees representing providers, employers, payors and policymakers. The conference highlighted the Chronic Care Model and provided specific examples of Maine providers who were using population-based approaches and information systems to improve care. In addition, links were made between Quality Counts and key health policy initiatives in the state, including Dirigo Health.

Quality Counts, Part 2 ,was held in April 2004, with more than 300 people attending. It featured Dr. Ed Wagner, primary architect of the Chronic Care model. The conference successfully engaged additional stakeholders, focused on further understanding and implementation of the Chronic Care Model and provided more specifics on how to implement its components in practice. At that meeting, Dr. David Stephens (then at AHRQ) challenged attendees by asking us whether we would simply all just disperse after the conference, or whether we would commit to working together on a continued shared agenda to improve chronic care. The group of conference planners took the challenge and quickly drafted the following mission ,which was brought to the full group of attendees and energetically endorsed at the end of the meeting:

“Quality Counts is committed to working together across organizations and across communities to improve healthcare systems and outcomes with the people of Maine. Quality Counts will work with Dirigo Health to coordinate existing but disparate efforts across the state that support local, patient-centered and coordinated systems of care AND the resources that support them. Its goals are to promote consistent delivery of high-quality care; improve access to healthcare; and contain healthcare costs.”

Following the success of the initial conferences, an advisory group was convened and held a strategic planning meeting in July 2004. The group reaffirmed a commitment to work together to promote comprehensive adoption and assessment of the Chronic Care Model across Maine, and adopted the mission noted above. The group further agreed that the primary organizational functions for Quality Counts would include

• providing leadership and serving as a change agent for promoting improved chronic illness care
• influencing state health policy
• advocating for change
• coordinating and inventorying existing improvement efforts
• improving communications between and among healthcare resources
• facilitating technical assistance such as training and education

Members of the advisory group were invited to become incorporators of Quality Counts (now member organizations), which subsequently created Quality Counts as a distinct corporate entity in June 2006. The QC incorporators then elected an initial board of directors representing employers, providers, government and consumers.

In February 2007 Quality Counts, in conjunction with the Maine Health Management Coalition and the Maine Quality Forum, was selected as the lead agency in Maine for the Robert Wood Johnson Foundation’s (RWJF) “Aligning Forces for Quality” (AF4Q) initiative, an effort that seeks to lift the quality of       healthcare by aligning efforts on performance measurement and public reporting, quality improvement assistance to providers and consumer engagement on the use of quality data. RWJF has recognized the AF4Q initiative as one of its major strategic initiatives and offered continued funding for this work, which has now expanded to include a focus on improving healthcare equity and changing payment systems. QC was granted 501(c)3 tax-exempt status as a public charity in April 2008.

Since that time, many other stakeholders in the state have joined QC and have contributed to its success as a multi-stakeholder regional improvement collaborative and neutral convener seeking to align improvement opportunities in the state. In addition to our work under AF4Q, and with the support of other grants and contracts, we have had the opportunity to lead several other improvement opportunities. These include the Maine Patient-Centered Medical Home Pilot and several hospital-related improvement initiatives. In 2009, QC engaged in a strategic planning process that updated our mission and identified the following vision and strategic priorities:

Mission: Maine Quality Counts is transforming health and healthcare in Maine by leading, collaborating and aligning improvement efforts.

Vision: Through the active engagement and alignment of people, communities and healthcare partners, every person in Maine will enjoy the best of health and have access to patient-centered care that is uniformly high- quality, equitable and efficient. 

Strategic Priorities:

1. Further increase system alignment to transform health and healthcare.
2. Promote a sustainable system of quality improvement assistance to all providers in Maine.
3. Foster meaningful consumer engagement in transforming health and healthcare in Maine.
4. Promote integration of behavioral and physical health.

A good number of national and statewide programs are gathered under the QC umbrella. Does QC serve as a clearinghouse or a junction, and does it have a mission other than that?
As outlined in our mission, Maine Quality Counts “is transforming health and healthcare in Maine by leading, collaborating and aligning improvement efforts.” As such, QC works with a wide range of stakeholders across the state to catalyze and implement systemic changes that are needed to truly transform the healthcare system. While we believe it is important to serve as a clearinghouse of information and initiatives related to quality improvement in Maine, and try to serve that function through our website, our “QI Directory” and our various educational offerings, we see our mission as more broad-reaching and action-oriented, and we’re pleased to have the opportunity to lead and align a wide range of improvement initiatives.

What kind of response have you had from the medical establishment in Maine?
The medical community in Maine has been very supportive of our efforts and has served as energetic partners in our improvement initiatives. We enjoy a strong relationship with physicians, nurses and other healthcare providers, as well as with the major health systems, hospitals, long-term care providers, home health and other allied health services. One of our fundamental beliefs from the outset has been that no single sector of the healthcare system is responsible for the current problems we face, and that no single sector should be expected to make the transformative changes needed to improve care without the involvement of all stakeholders. As such, I believe QC has been viewed positively by the healthcare provider community because we bring providers together with patients, employers, payors, government and other key stakeholders to work collaboratively to improve care.

There are some 40 or 50 hospitals in Maine. Do you work directly with any of them? Do you keep up to date on what is being accomplished there through the programs you represent? Do you have any way of measuring their efficacy?
We strive to work collaboratively with all sectors of the healthcare community in Maine, including Maine’s 37 acute care hospitals and the four major health systems. We have worked directly with the hospital community on several improvement initiatives, including the Maine Pressure Ulcer Prevention Collaborative that included 22 hospitals and 32 partnering long-term care facilities. Through our Aligning Forces for Quality (AF4Q) initiative, we have also had the opportunity to offer Maine hospitals opportunities to participate in national initiatives, with 11 Maine hospitals currently participating in the AF4Q “Hospital Quality Network” that helps hospitals improve care in several targeted areas, including reducing readmissions, improving emergency departments throughout time and improving the quality of language services. We are also now sponsoring the Maine Regional “Transforming Care at the Bedside” (TCAB) collaborative, an initiative that includes 23 nurse-led hospital teams working to empower front-line nursing staff to improve the quality of care. As an organization committed to data-driven improvement, all of our improvement initiatives include specific outcome measures, and participants are asked to track and report those measures as part of their participation.

Have you come across any medical organizations that are unwilling to cooperate in this initiative? Do you have any way of enforcing their compliance?
As a multi-stakeholder collaborative, QC encourages open participation in all of our educational events and improvement initiatives, while also recognizing that many providers face multiple competing demands for their time, energy and resources. As such, we understand that providers may need to prioritize their improvement efforts, and may not be able to participate in all the offerings made available. As a voluntary organization, it would not be appropriate for us to attempt to compel or persuade providers or other organizations to participate in our initiatives. But by aligning improvement opportunities with the other “drivers” of improvement in the environment (incentive programs or reporting requirements), we seek to offer initiatives that provide a service or fill a need for providers.

What would you say are the biggest barriers you encounter in promoting your mission? How do you maintain your public profile?
Some of the major barriers to promoting our mission are the limitations of time and resources available to support improvement work. As noted above, while we have robust provider support for our work, we recognize that we are one of many organizations that currently “compete” for the attention of providers who are being asked to improve on many fronts at once, and are under a wide range of regulatory and other obligations to participate in quality improvement and reporting activities. We are also functioning within a challenging financial environment, with increasing pressures being placed on national, state and local healthcare budgets that can sometimes limit the ability of organizations to dedicate resources to improvement activities.

We maintain our public profile through a range of communication vehicles, including our Web site (www.mainequalitycounts.org); a set of quarterly e-newsletters (general information, and a provider newsletter); an ongoing series of educational Webinars (QC Brown Bag Forum; Provider Lunch & Learn; and Nurse Leaders Lunch & Learn); periodic regional meetings; and our annual statewide conference, which typically attracts more than 500 stakeholders from across the state (QC 2012, April 4, Augusta Civic Center!).

What haven’t you been asked that you think people should know about QC?
I think it’s important for people to understand that QC is committed to aligning improvement activities in the state because we recognize the need for—and the power of—that alignment. As I noted previously, one of the challenges of the current improvement environment is the number of initiatives going on at the same time. While it is good to see a multitude of activities being offered, it can sometimes feel like improvement “chaos” to those working in the field. That chaos can be confusing and distracting, and can work against the goals of even the most well-intended efforts. Recognizing that challenge, QC has worked from our outset to align improvement efforts in the state, seeking to “create order from chaos” to help providers and other stakeholders better understand how various improvement efforts interconnect, and to stay focused on their improvement goals. To keep ourselves focused on this goal, the QC Board several years ago created a set of “Ten Simple Rules for Alignment.” (See www.mainequalitycounts.org/about/who-we-are.html).

A good example of this alignment is the Maine Patient-Centered Medical Home (PCMH) Pilot, an effort to improve both delivery systems and payment for primary care. Recognizing the growing interest in the medical home model, QC helped to catalyze this effort in 2008 by working with other key stakeholders in the state, particularly employers, payors and state government, to convene a planning process for a statewide pilot that brought all the payors together in a single pilot. Once Medicare announced its plans to launch its own medical home pilot in 2010, we coordinated efforts with other states to convince the federal government to bring Medicare into our existing state pilots as a key payor, rather than create a separate Medicare medical home pilot as initially intended. As a result of that effort, we are now one of eight states nationally to have Medicare participating in our state pilot, a strategic move expected to bring in more than $20 million in federal dollars to make this transformation work. We also have worked closely with MaineCare, Maine’s Medicaid agency, to align the pilot with its improvement efforts, and now see the medical home model as a key component of the MaineCare’s new “Value-Based Purchasing” program and its emerging Health Homes initiative. As a result of these efforts and the passionate commitment of Maine providers, we have moved from an initial 26 primary care practices working in the Maine PCMH Pilot, to now close to 100 practices that have worked to transform to the PCMH model of care– creating a growing medical home “movement” that offers great promise and serves as a foundational step to wider healthcare reform efforts in the state.

I think it’s also important for people to realize that QC exists because of the interest, energy and passion of the numerous people in the state who are committed to improving the quality of health and healthcare for the people of Maine. It was the reason we were created, and it is the reason we continue to exist and thrive. While those of us in the state may not always be aware of it, Maine is known nationally for its commitment to improving quality and its progressive healthcare environment. QC has been fortunate to tap into that commitment to excellence and the passion for innovation. We appreciate the willingness of all sectors of the state—i.e., healthcare providers, employers, payers, consumers/patients and families, government, public health and others—to work together to transform care.

In his 16 months as administrator of the federal Centers for Medicare and Medicaid Services, Dr. Don Berwick was at the center of the storm that surrounded the historic Patient Protection and Affordable Care Act (ACA) after it was passed on March 23, 2010. Though he was a self-admitted  newcomer to “the world of national policy and politics at the most tumultuous time for . . . modern American healthcare,” he had already developed and demonstrated firm convictions about the need for affordable healthcare for all Americans and the ways to make it happen. These beliefs were sharpened and focused during his tenure at CMS, and a few days after he resigned his post in early December 2011, he discussed his experiences ingovernment in an address he gave after receiving the 2011 Picker Award for Excellence in Advancing Patient-Centered Care. In this excerpt from that talk, Dr. Berwick discusses the social imperative for reducing healthcare costs, identifies the six most egregious areas of waste and propounds five principles to guide any cost-cutting efforts.

Click  here for the video.

A program to familiarize chief residents with the intricacies of treating geriatric patients with medically complex conditions is at the top of Jennie Chin Hansen’s agenda these days. Jenny has always been a dedicated and outspoken advocate for improving the quality of life and care for elderly patients, and  as the CEO of the American Geriatrics Society since April 2010, she is pursuing programs to accomplish that goal.

What is the program called?
The program is called Chief Resident Immersion Training, or CRIT for short.  It was developed at the Boston University Medical Center in 2003.

What is CRIT’s goal?
The two-day immersion program is intended to help chief residents better understand geriatric principles and give them the skills needed not only to treat this critical—and steadily growing—population, but also to educate younger physicians to the special needs of older adults with medically complex conditions.  CRIT encourages collaboration among different disciplines, and this too has been beneficial in bringing a better understanding of special geriatric issues to a much wider audience.

What has the program achieved to date?
A great deal, I’m pleased to say. It’s been disseminated to 15 institutions nationwide, where it has resulted in significant cultural changes in residency training and collaborative geriatrics care across a broad range of disciplines. Chief residents also report that CRIT has broadened their knowledge and understanding of geriatric issues as well as given them confidence in their ability to teach these skills to others.

As the geriatric segment of our population increases, this kind of program becomes more and more vital, and CRIT is filling that need admirably.

Note: The CRIT program is administered by the Association of Directors of Geriatric Academic Programs in partnership with Boston University Medical Center and supported by grants from the Hearst Foundations and the Donald W. Reynolds Foundation Program for Faculty Development to Advance Geriatrics Education

Dr. Don Berwick and Picker Institute Executive Director Lucile O. Hanscom.

Dr. Don Berwick, the winner of the 2011 Picker Award for Excellence® in the Advancement of Patient-Centered Care, will give the Picker Lecture at the 5th International Conference on Patient- and Family-Centered Care scheduled for June 4-6, 2012, in Washington, D.C. Details will be posted on the Picker Institute Web site (www.pickerinstitute.org) as they become available.

Dr. Berwick received the Picker Award at the 23rd annual  IHI forum in Orlando, Fla.,  in December 2011, several days after he resigned his post as administrator of the federal Centers for Medicare and Medicaid Services.

Click here to see a clip from Dr. Berwick’s acceptance speech at the Picker Awards ceremony.