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ENTERING INTO VALUE-ADDED PARTNERSHIPS WITH YOUR HMOs,[object Object],Roger H. Strube, M.D.,[object Object],Managed Care Consultant,[object Object]
The Cost and Cost Containment of Medical Care,[object Object],Roger H. Strube, M.D.,[object Object],Managed Care Consultant,[object Object]
The Cost = 18% of GNP$2.3 Trillion,[object Object]
NATIONAL HEALTH EXPENDITURES AS A,[object Object],PERCENT OF GROSS NATIONAL,[object Object],PRODUCT BY YEAR,[object Object],16,[object Object],15,[object Object],14,[object Object],13,[object Object],Percent,[object Object],12,[object Object],11,[object Object],10,[object Object],9,[object Object],8,[object Object],National Health expenditures as a,[object Object],percent of gross national product.,[object Object],7,[object Object],6,[object Object],1970,[object Object],1975,[object Object],1980,[object Object],1985,[object Object],1990,[object Object],1995,[object Object],2000,[object Object],Calendar Year,[object Object],Source:	Health Care Financing Administration, Office of the Actuary.,[object Object],	Data from the Division of National Cost Estimates.,[object Object]
Cost of Medical Care,[object Object],The issue is not the cost of,[object Object],Coronary Surgery,[object Object],The issue is the cost of,[object Object],diagnosing and treating,[object Object],Chest Pain,[object Object]
Sample of Actual Medical Knowledge,[object Object],(Tested Knowledge),[object Object],100%,[object Object],Knowledge Test Score,[object Object],100%,[object Object],75%,[object Object],75%,[object Object],B,[object Object],50%,[object Object],C,[object Object],50%,[object Object],25%,[object Object],25%,[object Object],D,[object Object],A,[object Object],0%,[object Object],0%,[object Object],20,[object Object],40,[object Object],60,[object Object],80,[object Object],100,[object Object],0,[object Object],Age (years),[object Object],Theoretical Test Scores,[object Object],“Changes over time in the knowledge base of practicing internists”Paul G. Ramsey et al, JAMA, August 28, 1991 - Vol 266, No8 pp 1103,[object Object],C,[object Object],D,[object Object],A,[object Object],B,[object Object],B,[object Object],C,[object Object]
100% Efficient Health Care*,[object Object],A Judgment Alone,[object Object],Maximum,[object Object],quality,[object Object],attainable,[object Object],using,[object Object],memory,[object Object],based,[object Object],system,[object Object],Quality of Care - Memory Base System,[object Object],TIME,[object Object],* Most cost efficient, medically necessary, effective and best expected result for the patient.,[object Object]
COMMUNITY HEALTH STATUS,[object Object],vs.UTILIZATION and EXPENDITURE RATE,[object Object],H,[object Object],ConservativeStyle,[object Object],ElaborativeStyle,[object Object],HEALTH,[object Object],STATUS,[object Object],of the,[object Object],POPULATION,[object Object],C,[object Object],B,[object Object],D,[object Object],A,[object Object],Range ofAcceptable Practice,[object Object],Underservice,[object Object],Overservice,[object Object],$/C,[object Object],SERVICES and EXPENDITURES PER CAPITA,[object Object],Source: Booz, Allen and Hamilton Inc.,[object Object]
EPIPHANY,[object Object],A spiritual event,[object Object],in which,[object Object],the essence of a truth,[object Object],appears to the subject ,[object Object],as in,[object Object],a sudden flash of recognition,[object Object]
A New ParadigmThe Hypotheses isan Iconoclasm,[object Object],It is impossible for physicians to make,[object Object],appropriate medical decisions using the,[object Object],present memory-based system,[object Object],The information is too great and the medical,[object Object],knowledge too broad for the mind to manage,[object Object],All physicians are on Mission Impossible,[object Object]
TONS,[object Object],Tons of,[object Object],Paper,[object Object],Printed in,[object Object],Medical,[object Object],Journals,[object Object],Not,[object Object],Shinola,[object Object],Growth of Medical Publishing,[object Object],Growth of Medical Knowledge,[object Object],Shinola,[object Object],TIME,[object Object]
Managed Care,[object Object],Managed care is not the cause of the,[object Object],physician’s problems, it is a response to the,[object Object],cost and quality issues resulting from the,[object Object],failure of the memory based medical decision,[object Object],making process.  Managed care is not simply,[object Object],another iteration of insurance or administration. ,[object Object],It is the major catalyst and driving force behind,[object Object],the most significant, positive changes in the,[object Object],American medical delivery system in this,[object Object],century.  It is the agent of change which will,[object Object],fundamentally alter how medicine is delivered.   ,[object Object]
100% Efficient Health Care*,[object Object],B Judgment & Feedback,[object Object],Augmented,[object Object],memory,[object Object],based,[object Object],system,[object Object],Outcomes,[object Object],+ Other Feedback,[object Object],A Judgment Alone,[object Object],Maximum,[object Object],quality,[object Object],attainable,[object Object],using,[object Object],memory,[object Object],based,[object Object],system,[object Object],Quality of Care - Memory Base System,[object Object],TIME,[object Object],* Most cost efficient, medically necessary, effective and best expected result for the patient.,[object Object]
PLATEAU OF COMPARABLE OUTCOMES,[object Object],O,[object Object],PRESSURE TO CONTROL COST,[object Object],B,[object Object],C,[object Object],PRESSURE TO SATISFY PATIENTS,[object Object],D,[object Object],A,[object Object],Q,[object Object],Q = QUANTITY OF MEDICAL SERVICES,[object Object],CONFLICTING PRESSURES ON THEHEALTH SERVICE DELIVERY SYSTEM,[object Object],O = CLINICAL OUTCOME,[object Object]
Malpractice,[object Object],  The “Malpractice Crisis” is not caused by the litigious society or too many lawyers.  It is the response of the patient to the errors which result from the failure of the memory based medical decision making process.  Half of the medical care delivered in America ($500 Billion Dollars) is unnecessary, inappropriate, ineffective or harmful.  “Defensive Medicine” is no defense as excessive testing and procedures do not result in better decision making and could do harm to the patient.  The solution is through electronic decision support tools applied in real time.,[object Object]
Continuous Quality Improvement,[object Object], The Application of   CQI to the Medical Care Delivery  System,[object Object],                                                                           Roger H. Strube, M.D.,[object Object]
Quality Assurance Model,[object Object],STRUCTURE		PROCESS	         OUTCOME,[object Object],Are the right	       Are variables monitored                 Are the results of,[object Object],people in the	      and reports evaluated                      treatments monitored,[object Object],proper positions	      by the right people	          or recommendations,[object Object],with the appropriate	      and are appropriate	          followed up and,[object Object],authority to	      recommendations made?	          re-evaluated?,[object Object],evaluate care?,[object Object],Credentials		Committees	         Catastrophes,[object Object]
Quality Assurance Model,[object Object],Regulator’s (& Hospital) Paradigm,[object Object],(Old Testament -- Individual Crime & Punishment -- Find the Bad Apple Model),[object Object],[object Object]
Satisfy regulatory requirements
Identify errors (crisis management)
Influence through committee and peer pressure
Draconian tools (fines, cease & desist orders)
Rely on individual case review,[object Object]
The management of all employee benefits (medical, workers comp, EAP, disability, etc.) will be awarded to a single full service financially sound entity
Purchasers are willing to pay for quality & value for the employee - if the health plan has the lowest price
Business awarded based on proof the MCO can deliver quality care at low cost (NCQA  certification, HEDIS data, recommendations from Consultants -RFP/RFI*)    			* RFP/RFI  =  questions consultants pirate from NCQA & HEDIS,[object Object]
An Introduction to Total Quality Management( TQM  )and theDeming Philosophy,[object Object],Roger H. Strube, M.D.,[object Object],Managed Care Consultant,[object Object]
The Study of Quality is the First Step in the Never Ending Journey of Continuous Quality Improvement,[object Object],TQM is a set of enabling components and a value system,[object Object],applied by the people in an organization which leads to a,[object Object],cycle of continuous improvement of the quality of the,[object Object],processes and and resulting outputs (outcomes) of the,[object Object],entity.,[object Object],A tool for organizational learning - the way an,[object Object],organization re-engineers their business to meet,[object Object],customer needs and expectations. ,[object Object]
Components of theHealth Care Industry,[object Object],[object Object]
Suppliers
Managers
Workers
Investors
Materials
Machines,[object Object]
Corporate,[object Object],Plan Management,[object Object],Plan Supervisors,[object Object],Workers,[object Object],Customers,[object Object]
- NEXT -- TOPIC -,[object Object]
W. Edwards DemingContinuous Quality ImprovementManagement Theoryfor theTRANSFORMATION OF BUSINESS THROUGHAPPLICATION OF THE FOURTEEN POINTS,[object Object],Roger H. Strube, M.D.,[object Object],Managed Care Consultant,[object Object]
The W. Edwards Deming Story,[object Object],[object Object]
invited back in 1950 by JUSE to consult on improving the quality of Japanese exports
Dr. Deming provided the quality improvement roadmap an promised, if followed, they would dominate world trade
Emperor Herohito awarded him the Second Order Medal of the Sacred Treasure for his efforts
The Japanese government created the coveted DEMING PRIZE which was awarded to Florida Power & Light several years ago,[object Object]
Look at the long term view for the organization
Develop a mission statement and make it a living document,[object Object]
Your goal should be to provide your “customers” with the best possible care in the most appropriate setting
Use industry standards and guidelines (“emenarem”*) to fulfill your customers’ reasonable expectations and constantly improve the services you provide* “emenarem” derived from the Milliman & Robertson criteria sets, as in “The director of cost containment told the UR nurse to ‘emenarem’ out of the hospital.”,[object Object]
POINT  THREECease dependence on inspection ("Quality Assurance") to achieve quality.  Eliminate the need for inspection on a mass basis by building quality into the product(medical care) in the first place.,[object Object],[object Object]
Quality comes not from inspection but from improvement of the process.”- W. Edwards Deming,[object Object]
POINT FOUREnd the practice of awarding business on the basis of price tag.  Instead, minimize total medical cost (eliminate unnecessary procedures.)  Reduce the number of suppliers for any one service (limited provider network) on the basis of a long-term relationship of loyalty and trust.,[object Object]
POINT FIVEImprove constantly and forever the system of production and service, to improve quality and productivity, and thus constantly decrease costs,[object Object],[object Object]
PLAN - DO - STUDY - ACT
PLAN:    Collect data to determine a plan of action
DO:        Take those actions that further the plan
STUDY: Study the results of the actions by collecting data to measure                  achievements,[object Object],[object Object],                  customer satisfaction and further the successful aspects,[object Object]
Practice Guidelines,[object Object],Measurement,[object Object],and,[object Object],Feedback,[object Object],You cannot manage,[object Object],what you don’t measure,[object Object],CLOSE THE LOOP,[object Object]
SEVEN QUALITY CONTROL TOOLS,[object Object],Cause and Effect Diagrams   (Fish Bone diagram),[object Object],Flow Chart                           ( How work gets done ),[object Object],Pareto Chart                                  ( y = # , x = type ),[object Object],Run Chart                           ( y = measure, x = time ),[object Object],Histogram                       ( y = #, x = measurement ),[object Object],Control Chart       ( y = #, x = time + SD limit lines ),[object Object],Scatter Diagram ( v1 vs v2, plot the dots - trend? ),[object Object]
POINT  SIX,[object Object],Institute training on the job,[object Object]
POINT  SEVENInstitute leadership (see point 12).  The aim of leadership should be to help people and machinesand gadgets to do a better job.  Leadership of management (government, insurance companies, H.M.O.s) is in need of overhaul, as well as leadership of production workers (providers),[object Object],[object Object]
It is the responsibility of the employees to try out and trust the new environment and polices, to learn skills, and to develop a different way of relating to their supervisors,[object Object]
Fear of making mistakes              2 Performance appraisal
Fear of punishment                      3 Ignorance of company
Fear of being powerless                   goals    to control the aspects of             4 Poor supervision,[object Object],    your professional life                   5 Lack of operational,[object Object],    because of the following:                definitions,[object Object],                                                            6 Not knowing the job,[object Object],                                                            7 Being blamed for,[object Object],                                                                system problems,[object Object]
POINT  NINE,[object Object],  Break down barriers between departments.People in research, design, sales, enrollment, claims processing, information systems, medical management, and delivery of care (providers) must work as a team, to foresee problems of production and in use that may be encountered with the product or service.,[object Object]
POINT  NINE,[object Object],Causes for barriers between departments:,[object Object],[object Object]
Ignorance of the organization’s mission and goals
Competition between departments, shifts, or areas
Decisions or policies lacking specificity
Too many levels of management that filter information
Fear of performance appraisals
Quotas and numerical work standards
Decisions and resource allocation without regard to memory
Jealousies over status and salary
Personal grudges,[object Object]
POINT  ELEVEN,[object Object],11a.	Eliminate work standards (quotas -- days/K, claims/hour, etc.) on the factory floor (insurance company or HMO production areas).  Substitute leadership.,[object Object],  11b. Eliminate management by objective,  Eliminate management by numbers, numerical goals.  Substitute leadership.,[object Object]
POINT  TWELVE,[object Object],[object Object]
12b. Remove barriers that rob people in management and delivery of care of their right to pride of workmanship.  This means complete abolishment of the annual or merit rating and of management by objective, management by numbers
Deming believed that performance appraisals destroy teamwork and focus on the short term
People must be viewed as the most valuable resource a company possesses
Pride in  their work is the essential, most important attribute of a highly productive worker ,[object Object]
POINT  FOURTEEN,[object Object],Put everybody in the medical care system to work to accomplish the transformation. The transformation is everybody's job,[object Object],[object Object]
Management should drive out fear and eliminate other inhibitors and barriers to quality improvement
Quality improvement must be proceeded first by education of employees on what quality means and the needs of the customers
Quality is not a department function
Quality improvement is a never-ending process
Inspection by the government or any other agency does not mean quality control
Quality improvement cannot be accomplished without the total involvement of employees ,[object Object]
Memory Based Medical Model,[object Object],[object Object],Provider’s Paradigm,[object Object],[object Object]
Achieve desirable clinical outcome
Care based on professional judgment
Care plan managed by command
Rely on past clinical experience and education,[object Object]
Quality Management Viewpoint Analysis Grid,[object Object],CQI		QA		Medical ,[object Object],Focus		Customer		Standards of	Patient needs,[object Object],			expectations	practice		,[object Object],Goals		Standards and	Identification and	Diagnosis and ,[object Object],process improvement	elimination of errors	treatment of illness,[object Object],MethodsStatistical analysis	Disaster Analysis	Memory based,[object Object], 					                                           decision making,[object Object],Management	Participative line	Staff Activity	Hierarchical line,[object Object],Style		Activity				activity,[object Object],Data Analysis	Statistical analysis	Individual case	Outcome analysis,[object Object], 			of process		review,[object Object]
Continuous Quality Improvement Model,[object Object],The New & Improved NCQA Methodology,[object Object],[object Object]
Delight the customer (member)
Minimize Variation (critical paths)
Improve the process
Manage through participation(the Doctor as Quarterback of the Team)
Monitor using statistical methods(Plot the Dots),[object Object]
Analyze and fix the process, not the people
Invest in your people -- training and education
Do it right the first time
Work as a team
Use data analysis to continuously improvethe process,[object Object]
The data will define potential (acceptable) outcomes
The knowledge based computer programs will present alternatives (cook book)
The physician must negotiate the ambiguities with the patient (informed consent)
The patient and the physician will agree on the most acceptable treatment (disease state management)
The outcome of the interaction will become part of the disease state data base (determine best practices)
The decision support tools (cook book) will be updated to incorporate best practices (close the loop) ,[object Object]
The focus on the customer  & process, measurement of standard elements, empowerment of the workers,  and constant environmental change is resisted by many middle managers in business and most medical professionals. ,[object Object]
Why Invest inContinuous Quality Improvement?,[object Object],[object Object]
Quality comes not from inspection but from improvement of the process.”
- W. Edwards Deming,[object Object]
NCQA   AccreditationThe Plan’s PerspectiveA Walter Mitty* StoryFantasy vs RealityRoger H. Strube, M.D.,[object Object],                * “The Secret Life of Walter Mitty” -- James Thurber,[object Object]
NCQA,[object Object],[object Object]
A partnership among purchasers, consumers, and health plans ,[object Object]
Purchasers
Health plans
Union representative
Consumer advocate
Health lawyer
AMA
Quality expert
State legislator,[object Object]
Kansas
Maryland
Massachusetts
Michigan
Minnesota
Oklahoma
Pennsylvania
Vermont,[object Object]
The Problem -- Complexity,[object Object],[object Object]
State Licensure
Federal Qualifications
Medicare Certification (HCFA)
PRO Review - Medicare
Medicaid (AHCA)

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Pharm Mfgr Advise1998