HCI3 BLOG

Submitted by hci3-usr on Friday, July 29, 2016 - 01:05

Newtown, Ct – July 29, 2016

It feels pretty good when we can make two steps forward and only one step back – Earlier this week, with our colleagues at CPR, we published our Fourth Annual Report Card on State Transparency Laws and while the grades haven’t changed much, when you scratch the surface a bit you find that a lot of positives steps have been taken by a large segment of the country, and that a few more could finally provide the majority of Americans with health care price information. That’s in stark contrast to what we found in our first report. Since then, legislators have taken the issue to heart and pushed through comprehensive legislation. While the implementation of those laws still lags, we know it’s only a matter of time, and that’s a big step forward. One of the important sections of our Report Card was written by our good friend Judy Hibbard and provides everyone, even those who aren’t interested in state-managed price transparency, a guide on how to convey price and quality information to consumers if – and that’s a big if – the organization conveying the information actually wants consumers to act on it. Because as we look around at what most states, health plans and employers are doing, in clear violation of Judy’s principles, you really can’t believe that they seriously want consumers to act on the information they provide. And then they act surprised when they don’t get the results they say they expected. For some, the task of marrying quality to cost should now be easier thanks to CMS’s release of a new star rating for Hospital Compare, but only to some because one of Judy’s recommendation’s is to marry price and quality information that is relevant to the specific condition, illness or treatment a consumer is looking for. CMS, however, has decided that an overall star rating is just as informative. However it can be misleading, and that’s a half step back.

What this means to you – Thanks to New Hampshire’s all-payer claims database, we were able to calculate average severity-adjusted costs for hysterectomies by facility, and we also calculated the risk-standardized rates of complications. While this graphic plotting the facilities certainly doesn’t conform to Judy’s recommendations, it can be the basis for a decision table that would. When we compared our quality measurement for these hospitals on hysterectomy procedures with the Hospital Compare rating, we found differences, which is not surprising. For example, while Dartmouth Hitchcock has an average star rating on the CMS website, it has a higher than average rate of complications for hysterectomies. And therein lies the rub with overall ratings because they fail to show specific results at the condition or procedure level, and that’s what’s really important to consumers. The nuanced approach to quality measurement is all the more essential as we all move increasingly towards value-based payments. And in that regards the government took a step forward this week by releasing a preliminary rule on three more mandatory bundled payment programs, covering cardiac procedures, severe fractures and heart attacks. As these types of programs are replicated in the private sector, the negotiated bundled payment becomes, de facto, the price. Marrying that price with an overall quality rating, however, will mislead some patients because there’s little doubt that a facility that is good at managing complex orthopedic procedures is not necessarily good at managing cardiac procedures or hysterectomies. And while the government’s move to implement these new bundled payments continues to augment the momentum of alternative payment models, the replication of the flaws embedded in the Comprehensive Joint Replacement program is a solid half step back. The proposed rule for the three new bundles continues to lack serious adjustments for patient severity, continues to put all of the control in the hands of the hospitals and freezes physicians out, and continues to prevent the significant opportunity to arbitrage sites of service, which we have shown has a big impact on lowering overall costs of care. This week could have been a two step forward week, but the unwillingness of this Administration to listen to thoughtful suggestions to improve programs, and its rush to fulfill a political agenda tied to a shrinking political calendar took us a step back. It’s not a total loss, but it is a lost opportunity.

Sincerely,

Francois Sig

 

Francois de Brantes
Executive Director

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Tuesday, November 11, 2014 - 11:09
There are almost 22 million veterans living in our country. That is 22 million lives. 22 million families. 22 million reasons to better our health care. These people have served and dedicated their time, families and lives to making sure… ...

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Friday, November 7, 2014 - 02:39
What happens when the people lose trust in you? You get kicked out – It might take a while, but it will invariably happen. And what's amazing is that those in whom the public has lost trust are always surprised… ...

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Tuesday, November 4, 2014 - 10:09
It is no secret that consumer-patients are left in the dark when it comes to health care prices. By looking at our most recent Report Card on State Price Transparency Laws, created with Catalyst for Payment Reform, it is… ...

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Sunday, November 2, 2014 - 03:53
In last week's issue, The Economist warned about the dangers of deflation – For an economy as a whole, deflation can be as serious a threat as inflation, and once caught in its jaws, it takes a lot of… ...

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Friday, October 24, 2014 - 01:38
The Nobel Prize in economics is often awarded to those who have developed simple insights about how behaviors and markets work…or don't – This year's prize went to Jean Tirole for his insights on how the principles of agency and… ...

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Friday, October 17, 2014 - 05:09
What does Sears' slow death teach us about health care in the US? – During the post-war period and all the way through close to the end of the 20th century, Sears was "the store". When consumers wanted to find clothing… ...

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Tuesday, October 14, 2014 - 12:00
We are seeing a shift towards the understanding and overall acceptance of “quality over quantity” when it comes to providing care to patients. It’s a shift HCI3 celebrates, but to some, like clinicians, these changes can come with many questions… ...

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Friday, October 10, 2014 - 01:43
Those who have been benefiting from a free lunch are now complaining that they'll have to pay for it – The squealing from Chicago's gathering of the free lunch beneficiaries was so loud it even caused a putative candidate for … ...

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Monday, October 6, 2014 - 11:03
HCI3 has a long-standing mission to improve the quality and affordability of health care. After all, it is what every patient deserves: reasonably priced, high quality care. It is also what providers strives for: to provide the best, reliable service… ...

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Friday, October 3, 2014 - 02:13
If it sounds too good to be true, it probably is – Last year, in its national scorecard on the use of "value-based" payment models, Catalyst for Payment Reform reported that health plans paid 90 cents of every premium dollar… ...

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Friday, September 26, 2014 - 01:55
And then there were none….If CMS doesn't heed the warning signs, this will be the headline in Modern Healthcare in a year, reporting on the participation of the ACO Pioneers. And despite the surge in interest in the BPCI, the… ...

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Monday, September 22, 2014 - 01:36
Bundled payment programs are being tested and implemented around the country. And while current programs have been considered to be on a relatively small scale, the Centers for Medicare and Medicaid Innovation’s (CMMI) Bundled Payment for Care Improvement (BPCI) and… ...

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Sunday, September 21, 2014 - 05:47
In the flurry of contradicting theories, it's important to take a step back from the trees and observe the forest – Now that some evidence has (re)surfaced on how reduced network choices can temper health care costs, proponents and opponents… ...

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Friday, September 12, 2014 - 09:52
Fourteen years ago, in response to the IOM's report on the Quality of Health Care in the U.S., employers banded together to demand greater transparency in the quality of health care – as we reported last year, the state… ...

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Friday, September 5, 2014 - 06:04
A little over a year ago, with the support of the Robert Wood Johnson Foundation, we published a report that established a new framework for defining and designing incentives, for both health plan members and providers – We chose the… ...

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Friday, August 29, 2014 - 12:28
In the dog days of summer we opened up the cooler to give everyone some lasting relief – Implementing innovative payment models is hard work, and it’s made all the harder when there’s endless discussions and debates about the boundaries… ...

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Friday, August 22, 2014 - 02:36
As P.T. Barnum was fond of saying, without promotion something terrible happens….nothing – That's certainly not the only reason behind the recent announcement by the Cleveland Clinic and North Shore Long Island Jewish hospital to partner in a growing cardiac… ...

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Tuesday, August 19, 2014 - 12:51
The push for improving the quality and affordability of health care is gaining momentum. It's an exciting, but challenging time as there is great need for additional support to implement successful payment reform programs. To provide that much needed support,… ...

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Monday, August 18, 2014 - 11:26
More than 80 procedures and conditions now available; goal is 80% coverage of all costs of care by 2015 NEWTOWN, CT — August 19, 2014 — A new milestone toward health care payment and delivery reform has been reached with… ...

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Friday, August 15, 2014 - 05:21
When I was growing up, my doctor was Dr. Pomerantz. He knew me and I knew him. I can't say the same for my current PCP – And yes, times have changed, but it seems today that the importance of… ...

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Friday, August 8, 2014 - 12:30
Here they go again twisting the truth for the sake of cheap headlines. Don't get taken in – In yet another piece of disingenuous writing that passes for "science", RAND has published an "evaluation" of the IHA's three-year bundled payment… ...

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Monday, August 4, 2014 - 02:18
HCI3’s Bridges to Excellence recognition program rewards clinicians who provide quality care to help patients manage chronic conditions AUSTIN, TEXAS – AUGUST 5, 2014 – To improve care for Texans with diabetes, Superior HealthPlan is partnering with the non-profit Health Care … ...

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Friday, August 1, 2014 - 02:44
The Empire Strikes Back – Last week, UnitedHealthcare announced that it would make its price transparency tool available to everyone in the country, irrespective of whether they are a UHC member. Health4Me, which is the name of the app, provides… ...

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Friday, July 25, 2014 - 10:28
As the scrutiny on narrow networks increases, the argument by proponents focus on the inherent cost savings they bring – Consumers are being told that less choice means lower costs. That's got to be intuitive, right? The lack of… ...

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Friday, July 18, 2014 - 03:48
We watch with horror as children are bombed in Gaza and blown out of the Ukraine sky, and the world's indignation mounts – Closer to home, Ashish Jha and other Patient Safety experts testify that U.S. hospitals aren't any safer… ...

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Friday, July 11, 2014 - 01:20
So far, this year, there have been an estimated 111,498 health care-related preventable deaths – That's more than due to any other cause and yet few seem to care and many of those that do have become desensitized to the… ...

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Friday, June 27, 2014 - 01:04
Once in a while, even the DC cronies should let facts get in the way of the "truth" – The "truth" in Medicare payment policy has been that the DRG system (also known somewhat incorrectly as the prospective payment system… ...

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Friday, June 20, 2014 - 12:51
Inertia is the resistance of any object to any change in its state of motion, including changes to its speed and direction. It is the tendency of objects to keep moving in a straight line at constant velocity – It… ...

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Friday, June 13, 2014 - 02:34
Could it be that incentives reform is having an effect? The latest figures from the U.S. Census Bureau (albeit sans Rx costs) shows that medical cost inflation continues to be moderate. Year-over-year hospital revenue is anemic at 2.9% after having… ...

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Friday, June 6, 2014 - 08:21
Is this the best that we can do? Those who purport to be in charge of provider and payer organizations, in both the private and public sectors, clearly don't ask this seminal question often enough. Let's take the recent surge… ...

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Monday, June 2, 2014 - 10:14
Payers report cost savings and some impact on quality WASHINGTON — June 3, 2014 — Bundled payment is no longer assigned only to pilot status as a number of public and private payers are committing to this model as a… ...

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Friday, May 30, 2014 - 12:43
Most new product introductions have a life cycle that is dictated by the pace of the industry in which it is placed – For electronic and communications products, the life cycle goes from introduction to mainstream adoption in a matter… ...

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Friday, May 23, 2014 - 02:11
Price matters and depending on a consumer's sensitivity to price the results can be good, bad or ugly – When consumers are insensitive to price, as is still the case for many health plan members, prices rise whether overtly or… ...

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Thursday, May 22, 2014 - 08:19
Policy makers, national hospital and physicians leaders share best practices; focus on how to best engage consumers in bundled payment programs WASHINGTON – MAY 21, 2014 – As efforts continue across the U.S. to improve the quality of health care… ...

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Friday, May 16, 2014 - 01:06
"We have to break people away from the choice habit that everyone has"….yes, that's an actual quote from an insurance executive only a few days ago – Only in this warped upside down lunacy of a non-market can such a… ...

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Friday, May 9, 2014 - 03:07
An apple a day keeps the doctor away….and if you don't want to eat apples, we'll force feed you – That's been the driving philosophy behind the "demand" side management by employers for decades. The focus on the demand side… ...

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Friday, May 2, 2014 - 12:38
Price Transparency and Bundled Payment are two keys to healthcare system reform – Both have recently received much attention and for good reason: they each present a tremendous opportunity to decrease our soaring healthcare costs. I believe that with adequate… ...

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Friday, April 25, 2014 - 01:12
Newtown, CT – April 25, 2014 In our recent Scorecard on Price Transparency, Massachusetts got a B – one of the best grades. So imagine our surprise when the Data Review Committee balked at our efforts to further the State… ...

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Sunday, April 20, 2014 - 10:12
Newtown, CT – April 18, 2014 We are our brothers' and sisters' keeper – Too often, in the hustle and bustle of everyday life and in the pursuit of corporate and other goals, we forget or reduce this moral dictum.… ...

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Friday, April 11, 2014 - 12:32
Newtown, CT – April 11, 2014 It's funny to see how fast the cockroaches scurry when you turn on the light – This week Medicare released a set of data on physician payments that's making a lot of folks nervous,… ...

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Friday, April 4, 2014 - 04:56
We call it the DNA of medical episodes because it tells you a lot about patients and the way they were managed (or mismanaged) – There are lots of different ways to look at how health care resources are being… ...

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Friday, March 28, 2014 - 01:40
What's the big deal about price transparency? After all, is it that important in helping consumers choose providers? This seems like a dumb question, but given how few states in the US provide information on the price of health care… ...

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Friday, March 21, 2014 - 08:09
Newtown, CT – March 21, 2014 There's another tail that tells a very different tale than last week's. It's the PAC tail. PACs are Potentially Avoidable Complications, something about which we've published a lot and that causes significant variations… ...

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Friday, March 14, 2014 - 08:19
Newtown, CT – March 14, 2014 What's the difference between unpredictable variation and unwarranted variation: Solvency – Think of it as the tale of two tails. The distribution of total costs per year for an average commercially insured population includes… ...

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Friday, March 7, 2014 - 01:21
Newtown, CT – March 7, 2014 The tide of change is rising, and it's got the hand-wringing ivory tower dwellers gasping for air – There are thousands of healthcare services researchers busily employed by hundreds of organizations across the country.… ...

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Friday, February 28, 2014 - 01:34
Newtown, CT – February 28, 2014 You only know if processes and systems are doing their jobs by monitoring outcomes. It's a lesson the NCQA refused to listen to and now the results are in – In 2002, shortly after… ...

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Friday, February 21, 2014 - 12:49
Newtown, CT – February 21, 2014 It's often more politically convenient to lock away some problems than to deal with them, and that certainly is the case today with the mentally ill – As reported in September by the WSJ… ...

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Friday, February 14, 2014 - 01:27
Newtown, CT – February 14, 2014 Imputed values aren't the same as inherent ones, but it seems as if too many are forgetting that distinction – Let's start with the values imputed by some policymakers on those who may now… ...

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Friday, February 7, 2014 - 03:23
Newtown, CT – February 7, 2014 Boy have I got a deal for you…Behind door #1 is a non-negotiable complex formula defined by the government that will yield a single "value" score of your performance, and behind door #2 is… ...

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Thursday, February 6, 2014 - 09:20
By Michael Painter, MD “‘Let’s go.’ ‘We can’t.’ ‘Why not?’ ‘We’re waiting for Godot.’” ― Samuel Beckett For the economists in our midst, demand is a critical but pretty dry idea: the quantity of a good or service a buyer… ...

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Friday, January 31, 2014 - 03:31
Newtown, CT – January 31, 2014 A fascinating interactive graphic sums up the drag on the economy created by U.S. health care expenses – The NEJM published a chart devised from work by Meredith Rosenthal and Laura Smith that helps… ...

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Friday, January 24, 2014 - 01:32
Newtown, CT – January 24, 2014 It's time to reimagine health plan benefit designs – The by-product of health benefit plans that have high deductibles and co-insurance is the current transparency revolution that is sweeping the country. The outcome of… ...

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Friday, January 17, 2014 - 12:18
Newtown, CT – January 17, 2014 "A glooming peace this morning with it brings. The sun, for sorrow, will not show his head. Go hence, to have more talk of these sad things. Some shall be pardoned, and some punishèd.… ...

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Tuesday, January 14, 2014 - 07:24
Change to an established and large institution is a long and difficult process. Think about the American Revolution. A small, but able group of passionate visionaries started a small movement in their towns and cities that grew to a unified… ...

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Friday, January 10, 2014 - 01:39
Is a 3.7% growth in U.S. health care spending a cause for celebration? The government seemed to think so. We beg to differ – The U.S. health care bill stands now at $2.8 TRILLION…a mind-blowing number. And while the GDP's… ...

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Monday, January 6, 2014 - 09:11
It's amazing how a number, however arrived at, if proposed by an "authority", has lasting power even when it's flawed – A few years ago, researchers at Dartmouth came up with what they felt was a reasonable minimum number of… ...

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Friday, December 27, 2013 - 12:46
Newtown, CT – December 27, 2013 In a few days the calendar resets and provides us an opportunity to measure what has improved and what still needs to – certainly we can and should celebrate that fewer are uninsured. We… ...

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Wednesday, December 25, 2013 - 12:34
Happy Holidays from all of us at HCI3!   With warmth and gratitude, the HCI3 team wishes you a joyous holiday season and a prosperous and healthy New Year!… ...

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Friday, December 20, 2013 - 01:49
Newtown, CT – December 20, 2013 With only a few days left before Christmas, the shopping frenzy is in full swing. Consumers are pouring through web sites, stores and catalogues, comparing prices, quality, and making decisions – Comparison-shopping isn't a… ...

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Wednesday, December 18, 2013 - 08:10
By Elizabeth Bailey, MPH Program Implementation Leader, Midwest Region At some point in our lives, we all become consumers of health care services. If we are lucky, our interactions with the health care system are few and far between –… ...

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Monday, December 16, 2013 - 12:11
What do we even mean by “value-based payments”? Technically, it means we’re paying for value, but what is value? Some have tried a quasi-mathematical approach by dividing quality into cost. However, the numerator is defined in either stars or percentage… ...

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Friday, December 13, 2013 - 01:16
Newtown, CT – December 13, 2013 At this time of year, bells are the harbingers of joy, telling us to pay attention to the upcoming Good News – Tomorrow, in Newtown, they will ring for a very different reason. At… ...

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Saturday, December 7, 2013 - 05:42
Newtown, CT – December 6, 2013 Is it reasonable to ask physicians to know the price of health care services? That was one of the topics debated this week during the Price Transparency Summit in DC, and, as for… ...

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Saturday, November 30, 2013 - 05:36
Newtown, CT – November 30, 2013 There are several hundred thousand people who are thankful that, come January, they will get something that is taken for granted in all other highly developed countries – good health insurance. Despite its false… ...

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Friday, November 22, 2013 - 01:18
Newtown, CT – November 22, 2013 It seems that, this week, in the battle between the price fixers and the price warriors, the latter had the upper hand – Last week the infamous (for good reason) RUC announced boldly that… ...

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Wednesday, November 20, 2013 - 11:35
By Stacey Eccleston Program Implementation and Research Leader The data is in!—an astounding 400,000+ patients die each year related to preventable harm occurring at hospitals across the U.S. This puts medical errors at the third leading cause of death in… ...

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Friday, November 15, 2013 - 12:49
Most of the time bad numbers are bad news, but sometimes they're not, at least not for all – According to a newly published report, the health care industry has the highest rate of worksite injuries for its workers. Leading… ...

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Friday, November 8, 2013 - 12:20
It should be self-evident that delivering healthy babies is good for everyone. Good for the child principally, but also good for the mothers, and good for society. And yet…two reports this week remind us of the chasm between what should… ...

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Wednesday, November 6, 2013 - 03:31
By Amita Rastogi, MD, MHA, MS Medical Director, Cost of Care Programs I initially trained as a cardiothoracic surgeon in India, in one of the apex institutions of Southeast Asia. When I moved to this country in 1988, I retrained… ...

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Friday, November 1, 2013 - 01:02
Trick or treat….only time will tell, but we do have some early signs, and it's a mixed bag. There's no denying that October has been a catastrophic month for the ACA. The rollout of the federal exchange is a disaster… ...

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Wednesday, October 30, 2013 - 07:59
By Douglas Emery, MS HCI3 Program Implementation Leader, Western Region Recently I had a wonderful opportunity to attend a site visit hosted by ThedaCare in Appleton, Wisconsin. For almost 11 years now, under the visionary leadership of Dr. John Toussaint,… ...

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Friday, October 25, 2013 - 02:01
What will it really take to make health care affordable? Zero increase in per capita costs for the next decade. Most might say it's simply impossible, that the very best we can hope for is that the rate of increase… ...

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Monday, October 21, 2013 - 02:08
Numbers often mask life’s reality. Politicians and policy experts speak about the unaffordability of health insurance and the high prices of health care, but what does that really mean? For many average American families, life’s reality is that insurance is… ...

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Friday, October 18, 2013 - 01:13
Newtown, CT – October 11, 2013 How much of a price premium can excellent quality demand? This is a question that we will be answering over the next several months and for which we already have insights to share. Health… ...

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Friday, October 11, 2013 - 11:15
Newtown, CT – October 11, 2013 Much like for provider incentives, consumer incentives must be directed at reducing the penchant for bad behaviors – that's basically the conclusion from the current experiments that are under way in value-based insurance design… ...

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Friday, October 4, 2013 - 12:00
Newtown, CT – October 4, 2013 There's a lot of talk about "big data" and its potentially transformative power in health care, and the Health 2.0 conference this week showed how transformative it could be – Feedback loops are the… ...

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Friday, September 27, 2013 - 09:49
Newtown, CT – September 20, 2013 As the central component of the ACA launches in a few days, it’s important to review the macro changes to US health care – Over the next three months several million uninsured and underinsured… ...

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Friday, September 20, 2013 - 12:39
Newtown, CT – September 20, 2013 In the on-going battle between the federalists and the constructionists, we see the balance shifting again to the States – While the ACA and its implementation might have set the tone, the breadth and… ...

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Friday, September 13, 2013 - 02:59
Newtown, CT – September 13, 2013 The fight between the medical industrial complex and the innovators is now in full swing – Several studies this week highlighted the manner in which the medical industrial complex feeds itself and the growing… ...

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Friday, September 6, 2013 - 12:32
Newtown, CT – September 6, 2013 In a few weeks the new health insurance exchanges will open for business and we shouldn't underestimate the importance of that event. Apart from finally providing all who reside in the US with an… ...

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Friday, August 30, 2013 - 12:59
Newtown, CT – August 30, 2013 Trends are down and we should rejoice, but let's not keep the eyes off the prize – According to a new CBO report, Medicare trends have decreased more than expected and the causes… ...

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Friday, August 23, 2013 - 04:45
Newtown, CT – August 23, 2013 "For too long, North Carolina patients have been in the dark on what they can expect to pay for common medical procedures when they are admitted to a hospital. This new law gives patients… ...

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Friday, August 16, 2013 - 12:25
Newtown, CT – August 16, 2013 When pressure builds, the steam has to eventually come out or the pot will blow up, and boy is the steam coming out – A few weeks ago Penn State announced that it was… ...

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Friday, August 9, 2013 - 02:38
Newtown, CT – August 9, 2013 Getting high on life. It's a funny expression, but sums up the discussion between internal motivation and external charges – Those who get high on life don't really need external charges to keep moving.… ...

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Thursday, August 1, 2013 - 01:08
Newtown, CT – August 2, 2013 A free ride is never free to the person who bears its cost, but it is to the person who hitches the ride– and therein lies the dilemma for most employers who are trying… ...

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Friday, July 26, 2013 - 08:58
Newtown, CT – July 26, 2013 A culture bred by opacity inevitably leads to denial of responsibility, and this week’s physician survey in JAMA should be the last nail in that coffin – if you haven’t yet read it, then… ...

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Friday, July 19, 2013 - 11:55
Newtown, CT – July 19, 2013 This week’s announcement by ACO Pioneers reminds us that culture does eat strategy for breakfast – Take for example the reaction of Atrius Health to the news that they were going to pay a… ...

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Friday, July 12, 2013 - 12:13
Newtown, CT – July 12, 2013 "Nothing astonishes people so much as common sense and plain dealing", sayeth Ralph Waldo Emerson – And this week two friends remind us in their writings that common sense is just that. First, Judy… ...

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Friday, July 5, 2013 - 01:13
Newtown, CT – July 5, 2013 Dogs can teach us a lot about the conflicts of motivation – Like many in suburbia, my dog wears a zapping collar that will discharge a small shock if she gets too close to… ...

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Friday, June 28, 2013 - 01:17
Newtown, CT – June 28, 2013 Those who can, do. Those who can't, teach. Those who can't teach, administer – We're reminded this week of these simple truths. Across the country, those who can are doing wonderful work. Communities are… ...

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Friday, June 21, 2013 - 01:24
Newtown, CT – June 21, 2013 Myths die hard, but that doesn't stop them from being myths – Earlier this week the Wall Street Journal published a point/counterpoint on pay-for-performance. I argued for (I really argued against FFS), while… ...

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Friday, June 14, 2013 - 12:29
Newtown, CT – June 14, 2013 It's only when the first large health system will have declared bankruptcy that we'll know there's hope for the US health care system – There have been other industries in which the players have… ...

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Friday, June 7, 2013 - 12:35
Newtown, CT – June 7, 2013 "You're either habitually excellent, or not."                                     Paul O'Neill, former CEO of ALCOA and Treasury Secretary Disproving… ...

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Friday, May 31, 2013 - 12:48
Newtown, CT – May 31, 2013 Health care costs vary significantly; we spend twice as much as any other country; and have the same, or lower outcomes in quality. That's the plain old truth because it's based on clear and… ...

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Friday, May 24, 2013 - 01:56
Newtown, CT – May 24, 2013 "Continuation of a 1.7% gap [health care cost increase – GDP increase] until 2040 would result in health care's absorbing 26% of the GDP, a level that would still pose problems for the economy… ...

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Friday, May 17, 2013 - 11:54
Newtown, CT – May 17, 2013 Alamosa is a small community nestled in the San Luis Valley, surrounded by the Rockies, in Colorado. It's also the site of an operational implementation of chronic care bundles and offers lessons for the… ...

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Friday, May 10, 2013 - 01:11
Newtown, CT – May 10, 2013 It appears as if we should get ready for a period of medical cost deflation, and to continue to fuel it – Several papers, summed up in a recent blog, show that the… ...

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Friday, May 3, 2013 - 12:29
Newtown, CT – May 3, 2013 Lourdes is a little town nestled in the Pyrenees mountains, on the banks of the river Gave, to which, every year, about 6 million pilgrims travel – of those, perhaps a third are afflicted… ...

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Friday, April 26, 2013 - 01:32
Newtown, CT – April 26, 2013 There's something afoot, which many seem to deny. It's the type of popular revolution that always catches us by surprise – Economists are arguing that the current slowdown in medical costs is simply an… ...

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Friday, April 19, 2013 - 02:05
Newtown, CT – April 19, 2013 As the legend goes, the Gordian Knot was cut in half by Alexander, revealing the ends, curled inside – Our own problems often seem just as intractable. Where are the ends from which the… ...

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Friday, April 12, 2013 - 12:15
Newtown, CT – April 12, 2013 Super-utilizers. It seems like a marketer's dream target audience, and, for some, it is. For most of us, it should be a target audience of a different sort – When Jeff Brenner first realized… ...

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Friday, April 5, 2013 - 02:31
Newtown, CT – April 5, 2013 The power of report cards is truly amazing, especially when it's on something for which everyone should get darn close to an A – Last month, with our friends from CPR, we published a… ...

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Friday, March 29, 2013 - 02:07
Newtown, CT – March 29, 2013 For anyone who has seen The Passion Of The Christ, the more chilling scenes involve the Devil offering the easy way out to Jesus – He doesn't take it, but we're not Him. Earlier… ...

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Friday, March 22, 2013 - 01:49
Newtown, CT – March 22, 2013 There's an old (therefore politically incorrect) saying that in the land of the blind the one-eyed man is King….or in the land of mediocre health care, the Kaiser – So sayeth and admits George… ...

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Friday, March 15, 2013 - 01:18
Newtown, CT – March 15, 2013 In most States, consumers are granted protection against unfair trade practices, such as bait and switch, or masked prices. This protection, however, doesn't extend to health care purchases – We all know that health… ...

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Friday, March 8, 2013 - 01:28
Newtown, CT – March 8, 2013 They call themselves the "Pioneers", but naming oneself such and being one is very different – When CMS was in process of issuing its final rule on what the "Pioneers" would be… ...

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Friday, March 1, 2013 - 03:16
Newtown, CT – March 1, 2013 "We've created a secure, prosperous island in an economy that is suffering under the weight of the riches those on the island extract. And we've allowed those on the island and their lobbyists and… ...

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Friday, February 22, 2013 - 01:27
Newtown, CT – February 22, 2013 Ninety tests and treatments out of thousands doesn't seem like a lot, but it is – And that's because, building on their important (albeit modest) initial work, the ABIM Foundation has gathered support from… ...

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Friday, February 15, 2013 - 01:48
Newtown, CT – February 15, 2013 A confidence interval is a simple measure of significance. It tells us, with a degree of certainty, whether or not a measure, a benchmark, or a goal has been achieved or exceeded – For… ...

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Thursday, February 7, 2013 - 12:35
Newtown, CT – February 8, 2013 The Good, the Bad and the Ugly….now playing at a health care spectacle near you – We've known for a while that activating consumer-patients and engaging them in intelligent and thorough discussions with their… ...

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Friday, February 1, 2013 - 12:25
Newtown, CT – February 1, 2013 In her poignant book on her husband's fight with cancer, The Cost of Hope, Amanda Bennett reflects on the complete lack of price transparency in health care – It's a theme that we… ...

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Thursday, January 24, 2013 - 02:33
Newtown, CT – January 25, 2013 20% – 54% – 91,000 – 10% – 7 – 790 – 10,400 – Respectively, the percent of household income used to pay for health care costs; the percent of American families for whom… ...

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Friday, January 18, 2013 - 12:59
Newtown, CT – January 18, 2013 "Americans used to do big things together. We squared our shoulders and met our challenges. Now it's time to mobilize for a new national project: Fixing our health care system once and for all."… ...

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Friday, January 11, 2013 - 01:19
Newtown, CT – January 11, 2013 With all the talk of medical homes, better care coordination, higher quality and lower cost, why are C-section rates in the US twice as high as recommended by the WHO, causing excess harm to… ...

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Friday, January 4, 2013 - 01:39
Newtown, CT – January 4, 2013 We too often think of an insurance contract as being between an insurer and an insured – and while that is true, there are two parallel and often uncoordinated parts to the health insurance… ...

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Friday, December 28, 2012 - 12:00
Newtown, CT – December 28, 2012 C…that's the overall grade for the CMMI's 2012 efforts to reform payment in Medicare – While the CMMI has been busy in 2012 launching a number of initiatives, the net impact on Medicare… ...

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Friday, December 21, 2012 - 03:15
Newtown, CT – December 21, 2012 "I'm as mad as hell, and I'm not going to take this anymore", Howard Beale (Peter Finch), Network, 1976. In his iconic role, Peter Finch expresses the deep frustration of the American public faced… ...

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Friday, December 14, 2012 - 12:30
Newtown, CT – December 14, 2012 Percentages often mask reality even when they reflect it, especially when they're about the impoverishment of Middle America – A new report this week from the Commonwealth Fund includes a powerful infographic that reflects… ...

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Friday, December 7, 2012 - 12:18
Newtown, CT – December 7, 2012 A few decades ago, Signal Detection Theory came to life – Its purpose was simple (to detect a signal when there's a lot of noise) and has shown great relevance to the practice of… ...

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Friday, November 30, 2012 - 12:13
Newtown, CT – November 30, 2012 We should remember that knights could afford their knightly behavior. Even then, extrinsic incentives were in play — A recent post by Bob Wachter reignites the debate about knights and knaves, and highlights the… ...

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Friday, November 23, 2012 - 01:37
Newtown, CT – November 23, 2012 From Maine to New Mexico, and Arkansas to Washington, the pace of change is accelerating – Now that the dust has settled on the elections, the realization has finally set in that we will… ...

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Friday, November 16, 2012 - 01:05
Newtown, CT – November 16, 2012 "Like many businessmen of genius he learned that free competition was wasteful, monopoly efficient. And so he simply set about achieving that efficient monopoly." Mario Puzo, The Godfather. And so the story goes for… ...

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Friday, November 9, 2012 - 02:11
Newtown, CT – November 9, 2012 One thing is certain now, the ACA is here to stay – and that means the move by Medicare and Medicaid towards value-based payments will continue to accelerate, and with it, the needed transformation… ...

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Thursday, November 1, 2012 - 01:33
Newtown, CT – November 2, 2012 On the wake of Irene, the importance of transparency took center stage and was applied to Sandy – The Governors of Connecticut, New Jersey and New York learned the lessons from last year's debacle… ...

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Thursday, October 25, 2012 - 07:11
Newtown, CT – October 26, 2012 How do we avoid continuously committing the seven deadly policy sins that undermine our ability to deliver the noble mission of health care? In an article this week Julie Appleby lists the seven factors… ...

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Friday, October 19, 2012 - 12:15
Newtown, CT – October 19, 2012 I see fewer patients a day, spend more time with each, practice costs are down, and revenue is up – That's not a pipe dream, nor is it the statement of a physician in… ...

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Friday, October 12, 2012 - 12:08
Newtown, CT – October 12, 2012 In the 1960s and early 1970s, deaths from car accidents rose to a peak of about 54,000 per year. They've never been that high since – and there are far more drivers and cars… ...

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Friday, October 5, 2012 - 12:56
Newtown, CT – October 5, 2012 It's time for a Consumer-patient's Right To Pricing Information Act – A 2011 Government Accounting Office report on Health Care Price Transparency concluded that: "meaningful price information is difficult for consumers to obtain prior… ...

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Friday, October 5, 2012 - 01:58
Newtown, CT – October 5, 2012 It's time for a Consumer-patient's Right To Pricing Information Act – A 2011 Government Accounting Office report on Health Care Price Transparency concluded that: "meaningful price information is difficult for consumers to obtain prior… ...

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Thursday, September 27, 2012 - 03:49
Newtown, CT – September 28, 2012 The Empire strikes back – Financial suicide isn't at the top of a health system's CFO's list of priorities, and yet that's what we seem to expect them to do by entering into voluntary… ...

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Friday, September 21, 2012 - 11:54
Newtown, CT – September 21, 2012 Blockbuster, Circuit City, and Kodak share a root cause to their decline and failure: they forgot that incentives drive function, and that function drives form – Why do we need a roll of film… ...

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Thursday, September 13, 2012 - 01:30
Newtown, CT – September 14, 2012 Healthcare, we are often told, is different, and shouldn't be compared to other industries. The Institute of Medicine begs to differ – In a recent report, the IOM went to great lengths to… ...

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Friday, September 7, 2012 - 12:28
Newtown, CT – September 7, 2012 Why is there always a tendency to go for the "or" instead of the "and"? Policy experts, physicians, health plan leaders and many in the industry shape their positions and strategies as alternatives. And… ...

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Friday, August 31, 2012 - 12:28
Newtown, CT – Aug 31, 2012 Ready? Set?….Whoa, hold on, and think before you sign on the dotted line – Two months ago, at the end of June, hospitals, health systems and other organizations submitted applications to the CMMI for… ...

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Friday, August 24, 2012 - 12:12
Newtown, CT – Aug 24, 2012 It's usually dangerous when we confuse the talkers for the doers – A recent paper published in the British Medical Journal had an innocuous enough title: "When Financial Incentives Do More Good Than … ...

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Friday, August 17, 2012 - 12:35
Newtown, CT – Aug 17, 2012 It takes a bridge to cross a chasm, and that's why we named it Bridges To Excellence – In 2002, a group of employers that included GE, Verizon, UPS, Ford, P&G, and Raytheon decided… ...

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Friday, August 10, 2012 - 12:09
Newtown, CT – Aug 10, 2012 It's tough to be good when you're encouraged to be very very bad – and two recent investigative reports highlight the very very bad behaviors of physicians from coast to coast. In California,… ...

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Thursday, August 2, 2012 - 01:20
Newtown, CT – Aug 3, 2012 18% — that's the portion of the GDP that's collected in taxes, and it's also the portion of the GDP that's consumed by national health expenditures. No wonder we have a problem. Now, of… ...

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Thursday, July 26, 2012 - 01:49
Newtown, CT – July 27, 2012 Why aren't patients protected as well as diners or workers? Across the US, municipalities send out their public health inspectors to ensure that diners are protected from serious harm or injury that can be… ...

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Friday, July 20, 2012 - 12:00
Newtown, CT – July 20, 2012 What will it take to have the rug pulled out from under the RUC? With CMMI moving evermore aggressively to institute value-based purchasing contracts with willing health systems, practices and hospitals, the arcane, opaque,… ...

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Friday, July 13, 2012 - 12:21
Newtown, CT – July 13, 2012 Two recent books summarize the massive potential for improvement in the delivery system and lead to this observation: It's the incentives, stupid! The Pittsburgh Regional Health Initiative and the ThedaCare Center for Healthcare Value… ...

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Friday, July 6, 2012 - 12:15
Newtown, CT – July 6, 2012 Joey Chestnut's win offers us a lesson on the power of intrinsic and extrinsic incentives – it took 68 hot dogs and buns to win, and the crowd went wild. The other contestants faded… ...

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Friday, June 29, 2012 - 12:52
Newtown, CT – June 29, 2012 Uncertainty carries a significant cost – it makes estimates more difficult, increases the potential business risks of any venture, and since most of us have a tendency to overestimate losses rather than gains,… ...

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Friday, June 22, 2012 - 12:46
Newtown, CT – June 22, 2012 Sometimes it's useful to consider the theories of Nobel Laureates – in his seminal work on Game Theory, John Nash exposes a situation in which an equilibrium can be reached where neither party can… ...

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Friday, June 15, 2012 - 12:09
Newtown, CT – June 15, 2012 There are only ten Commandments. Everything else is pretty much a guideline – During the next two weeks, hospitals, physicians, and others will decide whether or not to apply to the CMMI's Bundled Payment… ...

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Friday, June 8, 2012 - 04:16
Newtown, CT – June 8, 2012 In the mid 1960s, Frederick Herzberg laid out an important theory: the factors that lead to job satisfaction are different than the factors leading to job dissatisfaction – his paper on motivating a workforce… ...

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Friday, June 1, 2012 - 12:43
Newtown, CT – June 1, 2012 As the proverb goes, the person who says something cannot be done should not interrupt the person doing it. Nine months ago we were almost interrupted by an out-of-date and misleading report that said… ...

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Friday, May 25, 2012 - 12:21
Newtown, CT – May 25, 2012 On May 11th 1944, a few weeks before the allies land in Normandy, my grandfather (and namesake) dies in a concentration camp in Austria, of aggravated pneumonia, in an environment in which there was… ...

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Friday, May 18, 2012 - 12:21
Newtown, CT – May 18, 2012 Organizations that currently dominate an industry have, as the theory goes, survived a process of brutal evolution. How is it, therefore, that they can sometimes be so incompetent? Let's examine the evidence. A benefits… ...

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Friday, May 11, 2012 - 12:26
Newtown, CT – May 11, 2012 Clay Christensen's seminal work on innovation offers important lessons for healthcare – The most important is that disruptive innovations will force the centralization of skills to become decentralized. In other words, many aspects… ...

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Friday, May 4, 2012 - 01:01
Newtown, CT – May 4, 2012 It's good to know that sometimes things work out like you hoped they would – in a new report we released today we show that practices recognized under the NCQA Patient-Centered Medical Home recognition… ...

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Friday, April 27, 2012 - 01:24
Newtown, CT – April 27, 2012 What happens when you use a product for a purpose other than the one it was designed for? If you're lucky, it might work. But most often you get bad results. There are two… ...

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Friday, April 20, 2012 - 05:21
Newtown, CT – April 20, 2012 Sometimes, what's more important is who's not on a list than who's on it – Last week CMS released the list of the 27 initial organizations that have made the cut for the ACO … ...

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Friday, April 13, 2012 - 02:06
Newtown, CT – April 13, 2012 Health care utilization continues to be flat, yet total healthcare expenditures continue to rise by close to 4%, keeping healthcare at 18% of GDP. Time to unleash the price slayers – The most recent… ...

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Friday, April 6, 2012 - 01:29
Newtown, CT – April 6, 2012 What does it take to activate a consumer? Impact on the wallet and information on cost and quality – it's a super simple formula, and one that every employer in the US has understood… ...

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Monday, April 2, 2012 - 03:25
Newtown, CT – March 30, 2012 There's one simple lesson that keeps eluding many in our field: It's the design, stupid! Poorly designed incentive programs usually garner poor outcomes. For example, when CMS launched the Premier demo a decade ago,… ...

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Friday, March 23, 2012 - 04:59
Newtown, CT – March 23, 2012 Close to $200 million. That's the added "tax" imposed on Pittsburgh residents by the city's too numerous hospitals (a.k.a. UPMC) – Pittsburgh, Cleveland, Cincinnati and St. Louis have about the same number of people… ...

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Friday, March 16, 2012 - 12:45
Newtown, CT – March 16, 2012 Dr. Hammond, like many independent physicians, is trying to do his best to make ends meet and continue to serve his patients – And unlike many physicians, Dr. Hammond has received several Bridges To … ...

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Friday, March 9, 2012 - 02:49
Newtown, CT – March 9, 2012 "Assuming technical risk and offering a warranty is an effective way for providers to reduce information asymmetries" – this powerful insight by Michael Hicks of Pinnacle Partners summarizes the way in which health care… ...

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Friday, March 2, 2012 - 01:00
Newtown, CT – March 2, 2012 On Wednesday, potential CMMI Bundled Payment applicants received their 70 plus files of Medicare claims. In addition, CMS awarded its contract to build a public domain episode grouper – Another page has turned. For… ...

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Friday, February 24, 2012 - 01:49
Newtown, CT – February 24, 2012 Dutch auctions, inventory funding, public domain source code, conversational blogs ….healthcare – these aren't words that are usually associated together, and yet they are. A recent GAO report illustrated how even in the controlled… ...

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Friday, February 17, 2012 - 12:47
Newtown, CT – February 17, 2012 Following the First World War, the French built the Maginot line to protect themselves from another invasion. The Germans simply went around it – Faced with a potentially disruptive force, incumbents react in one… ...

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Friday, February 10, 2012 - 02:19
Newtown, CT – February 10, 2012 Over ten years ago, the Nobel Prize in Economics was awarded for work done on information asymmetries, a topic that was first brought to the attention of health care industry leaders in the 1960s… ...

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Friday, February 3, 2012 - 12:26
Newtown, CT – February 3, 2012 If, as recently reported by the CBO, high touch care management and payment reform work, why aren't they being widely deployed? This is our collective $500 billion question, because that's roughly what would be… ...

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Friday, January 20, 2012 - 12:59
Newtown, CT – January 20, 2012 Something's going on, and passing it off to the Great Recession is no longer holding water – The CMS's report on the growth of health care spend in 2010, and the Altarum Institute's estimates … ...

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Friday, January 13, 2012 - 02:14
Newtown, CT – January 13, 2012 Each quarter we highlight field activities and opinions from experts in our Newsletter, Improving Incentives – in this latest issue, you'll read about the launch of a new bundled payment initiative in Wisconsin… ...

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Thursday, January 5, 2012 - 06:09
Newtown, CT – January 6, 2012 As we start 2012, it's appropriate to reflect on the distance travelled in 2011 and the distance to be travelled these next twelve months – First, the leadership at the Innovation Center has yielded… ...

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Thursday, December 22, 2011 - 10:36
Newtown, CT – December 22, 2011 Consumers understanding that avoidable complications are costly, ever-improving information on the quality and cost of care, and smart apps that help consumers find the care they need – If these are on your Christmas… ...

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Friday, December 16, 2011 - 12:24
Newtown, CT – December 16, 2011 PepsiCo recently announced that it would waive employee costs for having certain surgeries done at Johns Hopkins. Perhaps it should consider Stockholm as well – Employers are increasingly designating Centers of Excellence for more… ...

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Thursday, December 8, 2011 - 03:21
Newtown, CT – December 9, 2011 There's an important principle of organizational change that, to date, has been mostly ignored: Form follows function, and function follows incentives – so the key is really to focus on the function (e.g. delivering… ...

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Friday, December 2, 2011 - 02:45
Newtown, CT – December 2, 2011 A Perspective by Bohmer in this week's NEJM identifies four habits of successful high value health systems, that can be summarized into two management principles — organizations (large and small) need relevant and timely… ...

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Thursday, November 24, 2011 - 07:13
Newtown, CT – November 25, 2011 For every pro, there always seems to be a con (and vice versa), which can lead to inaction – The recently released final regulations for Accountable Care Organizations have, more than others, elicited strong… ...

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Friday, November 18, 2011 - 11:27
Newtown, CT – November 18, 2011 Rockford, IL, is one of three original PROMETHEUS pilot sites and today we report on findings from that implementation – Last week Health Affairs released a qualitative review of three implementation sites, relating the… ...

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Friday, November 11, 2011 - 11:31
Newtown, CT – November 11, 2011 It's really pathetic when a reputable research organization sacrifices the integrity of their work for the sake of a few cheap headlines – And yet that's what RAND did this week. They issued a… ...

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Friday, November 4, 2011 - 03:00
Newtown, CT – November 4, 2011 Today is the day – By close of business, the window to file a letter of intent for the CMMI Bundled Payment pilot will be shut. The preliminary numbers are very strong and if the final rush… ...

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Friday, October 28, 2011 - 01:41
Newtown, CT – October 28, 2011 Why do smart professionals who individually get an A, collectively get a D – the grade given the US in the Commonwealth Fund's latest scorecard. It's mostly because they've turned into piece workers,… ...

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Thursday, October 20, 2011 - 02:48
Newtown, CT – October 21, 2011 It's taken more than 30 years, but Jerry Solon must be smiling from heaven – In 1967, Dr. Solon published a paper in which he describes a novel way to measure the use of… ...

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Friday, October 14, 2011 - 12:14
Newtown, CT – October 14, 2011 There's nothing more infuriating than hearing hospitals complain that lower costs for those who pay for health care means lower revenues to them and potentially fewer jobs – it's infuriating because while their bank… ...

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Friday, October 7, 2011 - 09:16
Newtown, CT – October 7, 2011 As episode of care payment (a.k.a. Bundled Payment) becomes more prevalent, private and public sector payers will have to work through member benefit issues – in particular when bundled payments are prospective budgets against… ...

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Friday, September 30, 2011 - 09:12
Newtown, CT – September 30, 2011 Our third-quarter newsletter comes out at an important time in the transformation of the U.S. health care system – A few weeks ago, CMS' Innovation Center launched the boldest and broadest pilot program in… ...

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Thursday, September 22, 2011 - 06:44
Newtown, CT – September 23, 2011 Earlier this week, Andy Webber and his team at NBCH hosted a webinar on the CMMI Bundled Payment Pilot – Valinda Rutledge, who is heading up this important effort at the Innovation Center, reviewed… ...

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Thursday, September 15, 2011 - 06:14
HCI3 Update from the Field – Newtown, CT Fall is a few days away and it's time to plant the bulbs that will come out in Spring – Many of those bulbs should be the Letters of Intent by Applicant-providers … ...

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Friday, September 9, 2011 - 03:00
Newtown, CT – September 9, 2011 As we approach the sad tenth anniversary of the September 11th 2001 events, we must take pause to consider the path traveled since and the path we must travel from now on – On… ...

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Friday, September 2, 2011 - 01:00
HCI3 Update from the Field – Newtown, CT The day the CMMI announced its Bundled Payment pilots, there were two tectonic shifts – the first shook the East Coast of the US, and the second will continue to shake the… ...

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Monday, August 22, 2011 - 08:39

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Friday, August 19, 2011 - 12:58

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Friday, August 12, 2011 - 12:49
HCI3 Update from the Field – Newtown, CT The time gap between knowledge acquisition and formal dissemination of that knowledge in peer-reviewed journals is maddeningly long – especially in an environment in which solutions are desperately needed today. This week… ...

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Friday, August 5, 2011 - 01:00
HCI3 Update from the Field – Newtown, CT In a week in which gloomy news has been followed by gloomier news, we were privileged to witness how payment reform efforts are having a really positive effect – some of our… ...

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Thursday, July 28, 2011 - 06:00
HCI3 Update from the Field – Newtown, CT Trajectories can be changed, and will be changed if everyone truly steps up to take a swing – two studies released this week provide a bleak picture of our current and future… ...

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Thursday, July 21, 2011 - 06:00
HCI3 Update from the Field – Newtown, CT 18 months and counting – that's the amount of time CMS has to launch the national episode of care pilot. In a new report released earlier this week by the Center for… ...

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Thursday, July 14, 2011 - 08:28
HCI3 Update from the Field – Newtown, CT A number of papers in this week's NEJM remind us of our challenges and opportunities – and do so in an adult and constructive dialogue that is quite refreshing given the imbecility… ...

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Friday, July 8, 2011 - 03:00
HCI3 Update from the Field – Newtown, CT Every quarter we release more in-depth news from the field – and this quarter is no different. In this newsletter we introduce several columns from our Board members. The Lawyer's Brief reviews… ...

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Thursday, June 30, 2011 - 06:17
HCI3 Update from the Field – Newtown, CT When the CFOs of many of the country's hospital systems got together this week at the HFMA's annual conference, the talk was all about the conversion from volume to value-based payment –… ...

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Thursday, June 23, 2011 - 06:09
HCI3 Update from the Field – Newtown, CT Turning data into actionable information is hard but essential in the effort to transform practices – and many times, it doesn't take a huge organization to do it. A case in point is… ...

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Thursday, June 16, 2011 - 02:04
HCI3 Update from the Field – Newtown, CT How can we move away from the status quo if we bake it into the design of new programs? We can't and shouldn't. Which is why I encourage everyone to carefully read… ...

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Thursday, June 9, 2011 - 02:45
HCI3 Update from the Field – Newtown, CT When does "no we can't" become "no we won't" – when the technical and operational barriers to implementing an innovative or disruptive program have been removed. At that point, what's left is… ...

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Friday, June 3, 2011 - 03:00
HCI3 Update from the Field – Newtown, CT There's an interesting contrast between what most of us think is right and what consumers want – Atul Gawande's recent commencement address to the graduating class of the Harvard Medical School perfectly… ...

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