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Sunday, January 18, 2015

Let a thousand banalities bloom

With respect to
"Leveraging Holistic, Transformational, Innovative, Disruptive, Patient-Centric and Empowering Digital Health Space Ecosystem Paradigm-Shifting Curations, including Seamless Agile Scrum Lean Six Sigma DMIAC Gemba Workflows and Big Omics Data Hadoop-coded Post-RDBMS, Post-SQL HL7® FHIR® API Synergistic Interoperability Solutions encompassing The Upstream, inclusive of All Stakeholders."
Crash Davis, - Bull Durham

I first came to health care ("healthcare"?) analytics in 1993 in the wake of years of writing 3GL/4GL "apps" code (pdf) in an environmental radioanalytics lab in Oak Ridge and then writing technical marketing literature (pdf) for an industrial diagnostics company in West Knoxville (I loved that gig, gave it up in deference to my sweetie).

After moving from Tennessee in 1992 in the wake of my wife's promotion and transfer to Las Vegas (Nevada Test Site radiation cleanup project QA Manager), I took up my first of three tenures with what was at the time known as the "Nevada Peer Review," a Medicare "PRO" (Peer Review Organization).

CMS, then known as "HCFA" -- the Health Care Financing Administration -- set about to "re-brand" the PROs into "QIOs" (Quality Improvement Organizations). We would henceforth progressively set out to "transform the healthcare system." No more stodgy post-hoc UTIL and "appropriateness of care" manual chart-abstration "QA" case reviews done by veteran, flinty-eyed, chain-smoking, shuffling floor-burnout-case RNs who could read adroitly across the dx and px codes and pt demographic data in the UB-82 output claims files (often with a cigarette in hand) and quickly paint you a vivid picture of the benes' clinical travails and their respective prognoses.

One of my first assignments (prior to our "QI Transformation") involved the empirical study of Medicare bene 5- and 30-day re-admissions in Nevada acute care facilities (pdf).

Another quick story from those days, as I originally posted on another of my blogs some years ago:
During my first tenure (early 1990's) serving as an analyst for the Nevada/Utah Medicare Peer Review Agency (they're now called "QIO's" - Quality Improvement Organizations), in addition to our core Medicare oversight work, we had a number of small sidebar contracts, one of which involved ongoing analytical assessments of the Clark County Nevada self-funded employee health plan. One morning I accompanied my Sup, our Senior Analyst Dr. Moore, to a regular meeting of the plan's Executive Committee, wherein we would report on our latest plan utilization/outcomes evaluation.

A portion of the morning -- perhaps a half-hour, IIRC -- was always devoted to hearing claims denials appeals brought by Clark County employees. This day, two appeals were heard: one regarding an outpatient medical claim, the other concerning a dental encounter. The total sum at issue was about $350. Both appeals were denied, thereby "saving" the plan this nominal amount.

Bored by this administrative tedium, as I sat at the conference table, I did a quick, rough estimate back-of-the-envelope calculation. About a dozen executive/professional people consumed a half hour adjudicating these disputes, or, equivalently, 6 FTE hours. Assume a plausible blended G&A-multiplied cost estimate of the total compensation time for all these folks, plus all of the clerical/administrative time consumed in the processing (and subsequently denying) of these minor claims from the moment of their filing to this very hour.

Clark County easily spent well in excess of an additional $1,000 to "save" $350 at the expense of these two hapless employees, by my reckoning.

Similar scenarios -- public and private -- surely play out every day within our "health care system." Clark County would have been way ahead to have simply vetted the initial claims for fraud and then paid them! (This is one observation implicitly at the heart of the "Universal Coverage / Single Payer" model.)

But, as my Senior Medical Director was fond of pointing out, "every misspent dollar in our health care system goes into someone's paycheck."
Fast forward 20-some years. I'm sure financially enervating claims processing hassles continue unabated, and CMS continues to "study" Readmits. Maybe this time we'll make significant "absolute rate reduction" headway on readmits. We have better data now.

Given that my wife and I were (and continue to be) huge Deming fans, I was ecstatic about the new QIO direction. We renamed ourselves "HealthInsight," and went all-in Kumbaya in an (only partially successful) effort to put our vestigial Utah/Nevada bi-state shotgun-marriage antipathies behind us (UPRO had acquired NPRO after the latter had lost its Medicare contract prior to my coming on board; the respective "cultures" could not have been more different -- straight-laced, Rated-G, cookies-and-milk LDS Utah vs neighboring Cutty, Camels, and Card-Counting Nevada).

We studied under the acclaimed Dr. Brent James at IHC to get up to speed on the latest in CQI Progressivism. I still have my 2" thick training manual. It's as relevant today as it was in 1994. Brent rocks.

Two subsequent episodic tenures with HealthInsight later (the latter concluding with my 2013 REC "retirement"), I'm still largely awaiting (yes, with some exceptions) all of these broadly systemic, paradigm-shifting transformations. Mostly what we see are hard-won incremental improvements, prevailing marginally over incumbent intransigence.

We do, however, seem to naturally excel at cherubic marketing cliches. I had my fill of them this week.

Oh, and, one I failed to mention: "The Uber of healthcare!"

Right. To go all hip-hop lyrical for a sec, healthcare needs an Uber like it needs another Gruber.


Couple of interesting comments over at THCB.

Indeed. I recall Dr. James cautioning us early on during our IHC training "don't think we're going to QI our way out of the larger societal problem."


Can Lean QI liberate health care systems from "the inefficient tyranny of annual budgeting"? From The Thedacare Center for Healthcare Value:

I've followed and repeatedly cited Dr. Toussaint's work across the life of this blog.

More to come...

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