20 People Who Make Healthcare Better - 2009

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Promoting the Benefits of Transparency and Disclosure
"It occurred to me during that meeting that the right way to do this was to just be completely transparent and tell everything about industry relationships that we have."—Guy M. Chisolm III, PhD

Much of the progress made toward improving the transparency of physician-industry ties in the past year can be traced back to Guy M. Chisolm III, PhD. After he helped launch an initiative last December to begin publicly disclosing physicians' financial relationships with drug and device companies on Cleveland Clinic's Web site, other academic medical centers and drug and device companies have followed his lead with their own voluntary disclosures. (Exclusive audio interview with Guy M. Chisolm III, PhD.)

The idea developed when Cleveland Clinic hosted the Association of American Medical Colleges' Forum on Conflict of Interest in Academe in 2006; Chisolm is on the steering committee for the organization and has made conflict of interest in medicine a focal point of his career. He spearheads Cleveland Clinic's conflict of interest committees, including one for the board of trustees; was a member of a joint AAMC-AAU Advisory Committee on Conflicts of Interest in Human Subjects Research; and is a member of Case Western Reserve University's Outside Interests Committee.

"It occurred to me during that meeting that the right way to do this was to just be completely transparent and tell everything about industry relationships that we have," he says.

Cleveland Clinic had received some sharp criticism in recent years because of its doctors' ties to pharmaceutical companies, but the new policy has now set a high standard for other organizations to follow. "The more I thought about it the more I reasoned that if we're an institution that highly values innovation and if we're pleased with intellectual property we develop from these relationships and … are pleased that our faculty are thought leaders . . . I couldn't think of any reason why we'd hide that."

As chair of Cleveland Clinic's Innovation Management and Conflict of Interest Committee, Chisolm—who is a cell biologist—not only developed the program, but was tasked with incorporating feedback and rolling it out to the physician staff. He started with the orthopedic surgeons, who have some of the closest ties to device companies, and received mostly positive responses from the start. After all, he wasn't trying to hinder physician-industry collaborations; he wanted to give patients a more nuanced view of the relationships.

Most patients only hear about physician relationships with drug and device companies when a scandal breaks about excessive payments or tainted research. But the majority of collaborations are actually beneficial, particularly for institutions with a heavy focus on innovation and development; it's the lack of transparency that typically causes problems.

The few bad apples, however, have begun to take a toll. Physician-industry ties have attracted the attention of legislators. Massachusetts recently passed an outright ban on all pharmaceutical marketing gifts to physicians and several other states have or are considering similar laws. Senators Chuck Grassley (R-IA) and Herb Kohl (D-WI) introduced legislation—dubbed the Physician Payments Sunshine Act—earlier this year to require makers of pharmaceuticals, medical devices, and biologics to publicly report anything over $100 given to physicians in a year.

Legislators aren't the only ones interested in physician-industry ties, however. Chisolm is interested most of all in what patients think. Since implementing the program, he has held patient focus groups and surveyed about 2,000 Cleveland Clinic patients, and the results have convinced him patients have a deep interest in their physicians' relationships. A large majority said they wanted to know about physician ties to drug and device companies and would even consider using that information when choosing a physician or facility. Most want even greater detail than Cleveland Clinic is currently disclosing.

Chisolm says the next step is to work toward some type of template for expanding disclosure. The current listings are fairly rudimentary—only company names are listed, not the amount of the relationship—in part to avoid discrepancies between two different reports. For instance, if Cleveland Clinic and a drug maker both disclose the same financial relationship with a physician and one includes reimbursement for travel expenses and the other doesn't, patients may perceive a discrepancy.

To that end, Chisolm has invited several companies and academic medical centers that have started posting similar information, as well as a representative from Massachusetts, to Cleveland to discuss possible uniform standards and general guidelines for adding details to disclosure reporting.

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Elyas Bakhtiari is senior editor for physicians and service lines for HealthLeaders Media. He may be contacted at ebakhtiari@healthleadersmedia.com.

Creating A Place for the Working Poor
"Everyone has something to offer, and you don't have to have a lot of money to give it."—Faith Coleman, NP

In retrospect, it was lucky for the folks in Flagler County, FL, that Faith Coleman, NP, got kidney cancer, and that she had no health insurance to pay for it. Through her inspiration, they now have a free clinic to help the working poor and middle class.

When Coleman was diagnosed, she was only two years into her new career as a nurse practitioner. But as a contract worker for a private physicians group practice, she had no employee plan and could not afford her own health insurance. (Exclusive audio interview with Faith Coleman, NP.)

There was no place for her to get free or even low-cost care in the county. So she had to take out a $35,000 mortgage on her home to pay for the treatment.

By 2005, her cancer was in full remission. But the episode enabled her to see that so many uninsured people just like herself were facing the same challenges. They aren't poor enough to qualify for Medicaid, but not wealthy enough to afford health coverage.

"I wondered, 'What do these people do?'" she recalls. "I guess they just die if there's no one there to help them."

Coleman determined to find a solution. With the help of her daughter and her Ford Explorer, she launched the Flagler County Free Clinic in the small and poor rural community of Bunnell, 14 miles west of I-95. A friend, retired area physician, John Canakaris, MD, donated a small building to set up the clinic.

She called on her friends and co-workers, gathered supplies, equipment, and amassed a steady group of volunteers, all along maintaining her full-time job as a nurse practitioner in nearby Palm Coast.

She publicized the project with fliers and sent letters to area churches.

With her urging, volunteers in specialty fields such as oncology, hypertension and endocrinology, especially diabetes, created a referral network. She obtained free medication samples from pharmaceutical companies.

And when they opened the doors for the first time in February 2005, "We had eight patients and eight volunteers," she recalls. "It only operated on the first and the third Saturdays of the month."

Since August 2008, the clinic has been operating on the first and third weekends each month, Saturday and Sunday, with about 80 patients each weekend. Every day the doors have been open but one, she's been there too.

"It's not work when you love what you do," she says.

She and her volunteers were surprised at first to see who their patients were.

"We thought we would get the western end of the county—the poorer end," she said. "We were amazed: 95% of our patients are coming from wealthier Palm Coast.

"That's where we started to understand about the working poor. The people we thought we would be treating on the western end in fact qualified for Medicaid and really didn't need a free clinic."

Now the clinic has 30 physicians and 122 volunteers. They've counted 6,700 patient visits in the last 41/2 years. "We've jumped a long way," Coleman says.

Their space has expanded with the help of the Seventh Day Adventist church.

Because so much is donated in material and professional service—including nebulizers, bed sheets, imaging tests, and wound dressing—the clinic has kept its annual expenses to about $6,000, all of which is contributed.

"People now know they don't throw out anything in the way of medical equipment," she says. "They now know to take it to Faith."

The clinic now has a partnership with a nearby technical institute, which is training medical assistants at the clinic. In exchange, the institute provides Coleman with an EMR system.

The clinic is now so popular, it is too crowded. "We have to turn people away, we're so busy," she says. "And we certainly could use more space."

Coleman, who turned 55 in September, says people "have a responsibility to our fellow human beings. Everyone has something to offer, and you don't have to have a lot of money to give it."

But she says she couldn't have done it without all the volunteers. "It's wonderful to have people who believe in the dream as much as I do."

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Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached at cclark@healthleadersmedia.com.

House Call Doc Promotes Home-Based Solution
"These people don't need to or want to go to the hospital,"—C. Gresham Bayne, MD.

For pioneering house call doc C. Gresham Bayne, MD, the solution to the healthcare crisis is astonishingly simple. The industry must stop the excessive, expensive, and futile hospital care now provided routinely to severely ill Medicare patients who'd rather stay home anyway.

Instead, doctors should keep these patients away from painful, undignified, and difficult ambulance transport and emergency rooms, where the system so often leads to uncomfortable testing, lengthy stays, and needless mistakes.

And they should do it the old fashioned way: with house calls. Grab a more sophisticated version of the proverbial black leather bag. Get in the car (preferably one equipped with a portable X-ray machine and lab and a few other gadgets) and go see the patient in her home.

"I'm an ER doctor, and we know 90% of these patients don't need to be in the ER," says Bayne, founder and president of San Diego-based Call Doctor Medical Group. "So I thought, why don't we make house calls and save 10 times the money. We can provide better care for the frail elderly. It's a no-brainer."

Instead of thousands of dollars in cost for an elderly Medicare patient with multiple chronic illnesses, the expense can be reduced to about $200, Bayne says. (Exclusive audio interview with C. Gresham Bayne, MD.)

"Call Doctor house calls average 90% less than the basic charge of an emergency room visit in San Diego, not including an ambulance charge usually over $500," he says. Most of his trips tend to established Medicare patients, or referrals from home health agencies.

It's been nearly a quarter century since he first had that bright idea, and the venture-capital-funded Call Doctor has lost money in every year but the last eight. Things started to turn the corner when Medicare changed its payment structure for this kind of care.

"Now Medicare is paying three times as much for a housecall as when I started. Now we can make a living at this."

And Bayne is still its hard-charging force. "Our waiting room is your living room," he says.

At one point, his company had 11 different call doctor operations in six states, although he has sold off all but the one in San Diego. His team of board-certified physicians, physician assistants, and a certified radiation technologist have made more than 300,000 house calls, but in San Diego, now perform an average 600 a month.

Bayne emphasizes that making a visit to the home—not relying on a nurse practitioner call service—can keep dreaded readmissions down. He proved as much in a Medicare demonstration project. With in-home monitoring care, only one patient out of 111 had to be readmitted within 12 months, he says.

Costly in-hospital procedures such as thoracenteses, cardoversions, spinal taps, complex laceration repairs, or relocation of dislocated joints are much cheaper, and usually more comfortable, if provided in the home.

Bayne says Call Doctor has achieved a number of firsts for a house call anywhere in the country: 1985, first lab and standard oximetry provided on a house call; 1986, first EKG; 1987, first portable x-ray developed on-site; 1995, first cardiac impedance sent wirelessly; 2007, first Bluetooth CO Starling Curve sent.

Bayne is very big on wireless systems and electronic tablets that retrieve or zap information to other providers in fractions of a second.

And on the payment end, Bayne is credited with persuading the American Medical Association to redefine the meaning of a house call in a way that expanded the number of payment levels from three to five, which more than doubled the amount of reimbursement.

Called "something of a gadget freak," by Time magazine, he has continued to work with manufacturers to fine tune devices that can easily be carried to a person's home, with more sophisticated transmission technology that can handle San Diego County's large distances, mountains, and valleys.

For example, he helped design a smaller, lighter ventilator and cardiac-impedance devices that were easily portable, he says. The ventilator is about the size of a Coke bottle and the impedance device resembles a cell phone.

Bayne wants to continue to help change policy. He and two others, with help from Congressional aides, helped write the Independence At Home Act, which recently passed out of the Senate Finance Committee on its way to health reform.

If it passes, provider teams that save at least 5% on eligible beneficiaries' healthcare costs, and improve outcomes and patient-caregiver satisfaction, may share in any additional monetary savings.

Bayne says the deficit is forcing Medicare to do right thing.

"Just remember," he says, "10% to 25% of the Medicare population has multiple chronic diseases and accounts for between 60% and 85% of all Medicare spending today. We can reduce that 10-fold, which is easy to do on house calls. These people don't need to or want to go to the hospital."

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Cheryl Clark is a senior editor for HealthLeaders Media Online. She may be contacted at cclark@healthleadersmedia.com.

A New Alternative: Measuring and Paying for Outcomes
"The whole idea of switching process measures out for outcomes measures was a new idea for targets under the incentive program."—Cleve Killingsworth

Blue Cross Blue Shield of Massachusetts CEO Cleve Killingsworth has been preaching the need for more quality in healthcare for more than a decade. Even before the Institute of Medicine's Too Err is Human, Killingsworth was promoting quality as president and CEO of Health Alliance Plan in Detroit. (Exclusive audio interview with Cleve Killingsworth.)

Killingsworth says the Institute of Medicine study shined a light on healthcare quality and gave health insurers quality data that they could use during hospital contract negotiations.

Killingsworth was hired as president and COO of Blue Cross Blue Shield of Massachusetts five years ago, partly because of his quality focus at Health Alliance Plan. He became CEO when William C. Van Faasen retired in 2006, after being named to the position in July 2005.

Killingsworth says Van Faasen took a struggling Blue Cross plan in 1996 and turned it into an "excellent operating company." Once the CEO turned around the company, Killingsworth says, his next goal was to improve the delivery system.

The first step in this change to quality is shifting focus from the usual health insurance business of paying claims, selling products, answering phones, and dealing with brokers to figuring out problems with the system, reducing clinical waste and harm, and improving quality, he says.

Killingsworth says BCBS of MA first researched patient safety and quality data to understand the extent of the problem, such as that there are five million cases of unnecessary injuries in hospitals and that many doctors are prescribing antibiotics that are not helping the patient, but merely building up a resistance to those medications.

"There's a whole list of problems with the delivery system that you can talk about. Once you teach people about the magnitude of the problem, it leads directly to the question: How do you approach that—given the unique responsibility and accountability of a large Blue Cross plan as we are?" he says.

The next step is changing the way the insurer pays providers so it leads to high-quality effective care. The idea is to build a new set of incentives based on eliminating clinical waste, but also retargeting goals.

Improving quality goes beyond targeting process measures, but also focuses on outcome measures. For instance, BCBS of MA doesn't just want a doctor to perform A1c tests for diabetes patients, but keep them within acceptable A1c levels, he says.

"The whole idea of switching process measures out for outcomes measures was a new idea for targets under the incentive program," he says.

One such initiative is the Alternative Quality Contract (AQC) that combines two forms of payment. The first is a global, or fixed, payment per patient adjusted for health status and performance incentives tied to the latest nationally accepted measures of quality, effectiveness, and patient experience. That's combined with performance incentives based on quality and safety metrics.

BCBS of MA's AQC created a payment system in which physicians get paid more than traditional contracts if they achieve certain quality measures. The global payment is meant to cover all healthcare services and is the same level that doctors get paid in traditional BCBS of MA contracts.

"What we're doing here is starting at levels doctors and hospitals have already achieved and extended that level in the AQC environment. We're not taking money out of their pockets to get this done," he says.

On top of the global payment are performance incentives, which can raise reimbursements by up to 10%. BCBS of MA has signed up 12 physician groups and hospitals for the AQC.

Though outcomes measures are the target in AQC, Killingsworth says process measures are still a way that the insurer can know that providers are "giving their patients as much care as they need. One criticism of capitation contracts is that people were being given less care than they needed. I don't think that was ever proven, but it was a perception."

Though BCBS of MA has been a leader in quality, Killingsworth predicts a greater movement toward quality throughout the healthcare system. National health reform will bring greater emphasis on cost and quality and, at the state level, Massachusetts plans to change from a fee-for-service payment system to a global payment within five years. Killingsworth says this move to quality will mean BCBS of MA's competitors will have to offer similar programs in the near future.

As AQC expands to more physician groups, Killingsworth says his insurer will work with doctors to make sure they are successful in the program. This program is about more than gaining a larger market share, he says.

"This is not about making more money or getting bigger for Blue Cross, it's about doing the right thing. Making sure our members get the most effective and safest care possible. There is some distance from where we are and the care that our members and other people in the community should expect," he says.

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Les Masterson is senior editor for health plans for HealthLeaders Media. He may be contacted at lmasterson@healthleadersmedia.com.

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