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Bradley B. Price MD
retired from clinical practice 9/7/17, but I am still working to reduce maternal mortality and ultimately transform the entire American healthcare system. I am sharing relevant critical information here.
How to Survive Pregnancy--
Twelve Practical Steps to Reduce Risk for You and Your Baby
More on Maternal Mortality Prevention
Executive Summary September 2018
The Maternal Mortality and Morbidity Task Force (Task Force) and Department of State Health Services (DSHS) jointly submit the 2018 Biennial Report as required by Chapter 34, Texas Health and Safety Code, Section 34.015. The Biennial Report contains Task Force and DSHS findings, and Task Force recommendations, developed in consultation with the Perinatal Advisory Council, to help reduce the incidence of pregnancy-related deaths and severe maternal morbidity in Texas. Findings from Task Force case review, statewide trends for maternal death, maternal death trends for the most at-risk populations, and statewide trends for severe maternal morbidity show that opportunities exist to address causes and contributors to maternal death and morbidity in Texas. In addition, the Task Force and DSHS recognized potential areas for operational improvements to the maternal death case review processes.
Summary of Recommendations:
- Increase access to health services during the year after pregnancy and throughout the interconception period to improve the health of women, facilitate continuity of care, enable effective care transitions, and promote safe birth spacing.
- Enhance screening and appropriate referral for maternal risk conditions.
- Prioritize care coordination and management for pregnant and postpartum women.
- Promote a culture of safety and high reliability through implementation of best practices in birthing facilities.
- Identify or develop and implement programs to reduce maternal mortality from cardiovascular and coronary conditions, cardiomyopathy and infection.
- Improve postpartum care management and discharge education for patients and families.
- Increase maternal health programming to target high-risk populations, especially Black women.
- Initiate public awareness campaigns to promote health enhancing behaviors.
- Champion integrated care models combining physical and behavioral health services for women and families.
- Support strategies to improve the maternal death review process.
Information on Improving American Healthcare
Ten Crucial Steps To Fix American Health Care
- Transition from fee-for-service to value-based payment systems: Earnings of doctors, clinics, and hospitals increase the more services they provide. To counteract this perverse incentive, insurance companies devised managed care, which has failed to rein in costs because it is essentially a zero sum game of cost shifting between payers, providers, and patients-- which no one wins and everyone hates.
The solution is to pay for health outcomes that matter to patients while reducing the cost of delivering those outcomes. Medicare is already using this type of payment strategy for hip replacement. Converting to a value-based health care system would require no new taxes and could deliver cost savings immediately.
- Make health care costs transparent: Every provider, clinic, hospital and urgent care facility should inform each patient whether or not their insurance is accepted, and if not, what the likely cost will be. Doctors and hospitals should post prices for office visits, procedures, and surgery. Doctors are also honor-bound to inform every patient of any conflict of interest, for instance if the doctor is receiving payment for prescribing certain drugs or devices.
- Report clinical outcomes to the public: Doctors and hospitals should report clinical outcomes important to patients. For example, a gyn surgeon might summarize her hysterectomy data for the past calendar year, including total number, complication rate/type, and average number of days hospitalized. Using this type of data patients could look nationwide for the best reported outcomes for a needed procedure or surgery. Walmart is already sending employees who need joint replacement surgery from throughout the nation to Cleveland Clinic because of excellent publicly reported clinical results there. It’s also crucial to make routine, predictable services shoppable nationwide.
- Incentivize primary care and preventive health:
Double the average salary and forgive student loans for primary care physicians years who practice at least 4 years in value-based payment systems for underserved urban or rural patients.
Increase pay for primary care doctors who meet or exceed risk-based outcome measures. Risk-based means a doctor who cares for many diabetics and severe hypertensive patients, for instance, would be expected to have more hospitalizations per year than a doctor with few such patients.
Payers should pay for cost-effective preventive health measures, such as walking ten thousand steps per day, documented by free, highly accurate step counters available as smart phones apps and for keeping a food diary, supplemented by grocery receipts, while implementing better food choices, such as the Mediterranean or American Heart Association diet.
- Slash drug costs: Authorize drug makers to submit bids every two years for medicines covered under Medicare Part D, so that US patients can lock in the lowest bid for their medication every two years.
End monopoly price gouging for generic drugs.
As drugs come off patent, the brand drug maker may not block or delay the brand-to-generic conversion.
Pharmacy benefit managers need to disclose any rebates received from drug makers.
- Expand Medicaid: to the hard working people who earn up to $17,236 annually (138% of the federal poverty level) and are not offered health insurance at work. This strategy is particularly important for Texas, the state with the highest percentage of uninsured in the nation. Texans should stop sending tax money to Washington DC while 36 other states are getting nine dollars back for every dollar they spend on Medicaid. This cash flow would help tax-supported urban hospitals reduce property taxes and help cash-strapped rural hospitals stay in business.
To help reduce rising maternal mortality, continue Medicaid benefits for one year after covered women deliver, since women currently lose coverage 8 weeks after delivery, and a large number of maternal deaths in Texas occur up to one year postpartum.
- Expand Medicare incrementally:
Reduce the age that Americans qualify for Medicare while keeping employer-based health insurance intact. This incremental approach allows time for payers and providers to initiate value-based payment systems that can decelerate the rise in health care costs.
- Target high users for special care: 5% of the American population accounts for 50% of all medical expenses. These are people with complex medical needs, often complicated by homelessness, substance abuse, and psychiatric issues. These challenging social determinants of health lead to frequent ER visits, poor compliance with recommended care, and many hospitalizations for preventable problems. The Commonwealth Alliance in Boston is tackling this problem by organizing teams of doctors, nurses, social workers, and behavioral health specialists to provide care which keeps these “high users” healthy and out of the hospital.
- Make timely, efficient behavioral health care available for all, especially by easing restrictions on telemedicine.
- Make medical records readily communicable nationwide: Block chain technology can make electronic medical records immediately and securely available to payers, providers, hospitals, and patients throughout the nation. Payers could potentially use this information instead of insurance claims. Congress needs to pass appropriate legislation to clear the logjam of proprietary electronic medical record systems that cannot or will not communicate with each other.
References by Topic:
- Transition from fee-for-service to value-based payment systems:
- Redefining Health Care: Creating Value-Based Competition on Results, Michael Porter and Elizabeth Teisberg, Harvard Business School Press, 2006
- “Introduction to Value-Based Medical Care”, seminar led by Scott Wallace and Elizabeth Teisberg at the Institute for Value in Health and Care, 2018, University of Texas Dell Medical School, Austin, TX
- “Creating a high-value delivery system for health care”, Teisberg and Wallace, Semin. Thorac Cardiovasc Surg.,2009 Spring:21(1):35-42
- “How physicians can change the future of health care”, Porter and Teisberg, JAMA. 2007;297(10):1103-1111
- “Transforming health care: Toward Value”, Porter and Teisberg, Managed Care Journal, 9/2017
- “Measuring What Matters: Connecting Excellence, Professionalism and Empathy”, Wallace and Teisberg, vitalsignsut.files.wordpress.com/2018/02/01
- “Redefining competition in health care”, Porter and Teisberg, Harv Bus Rev,2004 Jun:82(6):64-76, 136
- “Is There a Cure for This Fever? Measuring the Wrong Metrics May Incite Physician Burnout”, Jeff Apple MD, Travis County Medical Society Journal, May/June, volume 64, number 3
- “Value-Based Medical Education in Obstetrics and Gynecology: A Paradigm Shift”, Amy Young, MD, Obstetrics and Gynecology,Vol.130,No. 4, October 2017
- “United Healthcare launches bundled payments for maternity care”, Morgan Haefner, Becker’s Hospital Review, 5/9/19
- “14 health systems, insurers convert nearly half of business to value-based arrangements” Kelly Gooch, Becker’s Hospital Report, 12/18/18
- “Measuring Progress: Adoption of Alternative Payment Models in Commercial, Medicaid, Medicare Advantage, and Fee-for-Service Medicare Programs”, Health Care Payment—Learning and Action Network.org, Report 10/22/18
- “HHS to launch new mandatory bundled payment models: 4 thing to know”, Ayla Ellison, Becker’s Hospital CFO Report, 11/9/18
- “Does private Medicaid managed care save or waste money?” , Chad Terhune, Health News from NPR, 10/18/18
- “Health Care Spending in the United states and Other High-Income Countries”, Papanicolas, Waskie, and Jha, JAMA 2018 Mar 13:319(10):1024-1029
- “Price and intensity identified as the Major Drivers of Rising Healthcare Spending”, PetersonHealthcare.org, 11/8/17
- “A Short History of American Medical Insurance”, John Steele Gordon, Imprimis, September 2018
- Make health care costs transparent:
- “Five must-reads on healthcare price transparency”, Kelly Gooch, Beckers Hospital Report, 3/11/19
- “Seven Factors driving up your health care costs”, Julie Appleby, PBS Health, 10/24/12
- Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, Marty Makary, MD, Bloomsbury Press, 2012
- Report clinical outcomes to the public:
- “The role of patient-reported outcomes in women’s health”, Gregory, Korst, Saeb, Fridman; OBG Management, March2018, Vol. 30, No.3
- “Goodbye measures of data quantity, Hello data quality measures of MACRA”, Hasley and Levy, OBG Management, 4/2016, Vol.28, No. 4
- Incentivize primary care and preventive health:
- “Association of Primary Care Physician Supply with Population Mortality in the United Sates, 2005-2015, Basu, Berkowitz, Robert Phillips, Billton, Landon, Russell Phillips; JAMA Intern Med, 2/18/19
- “Ready, Risk, Reward: Improving Care for Patients with Chronic Conditions, White Paper, Premier Healthcare and Robert Wood Johnson Foundation, 2/12/19
- “72% of Americans are Overweight or Obese”, 2015-16, Center for Disease Control and Prevention, National Center for Health Statistics, Fast Stats Homepage: Obesity
- “Two ways Texas can save money and reduce teen pregnancies: Earlier age of consent and automatic enrollment of young women in health programs”, Molly Clayton, Texas Campaign to Prevent Teen Pregnancy
- “Move more, Sit less, Start younger”: Physical Activity Guidelines for Americans, 11/12 /18, health.gov
- Medicare Diabetes Prevention Program, CMS pay-for-performance program, cms.gov, 10/16/18
- “Reduce Heart Disease Deaths Through Food Price Changes”, Tufts Nutrition Letter, November 2017
- Slash Drug Costs:
- Drug Pricing Policies Find New Momentum, Shefali Luthra, Kaiser Health News, 1/25/19
- “Three Essentials for Negotiating Lower Drug Prices, David Blumenthal, CommonwealthFund.org, 8/22/18
- “Sanders, Cummings Introduce Bill Addressing Price of Drugs”, Reuters, 1/10/19
- “Intermountain, Ascension, , HCA, Mayo Clinic, Trinity Health and 12 other systems launch non-profit Civica generic drug company to address high costs and chronic shortages of generic medications”, BioSpace, 1/25/19
- “A 5-Point Plan to Lower Rx Prices: A memo to Washington”, Linda Marsa, AARP.ORG/Bulletin, May 2019
- “Your Medicine May Come with a New Side Effect: Financial Pain”, Kara Brandeisky, Money.Com, March 2016
- Expand Medicaid:
- Texas Maternal Mortality and Morbidity Task Force Biennial Report, Executive Summary, September 2018
- “Deadly Deliveries: Childbirth Complication Rates at Maternity Hospitals in 13 States” (including Texas), USA Today, 3/7/19
- “Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012-2015”, Admon, Winkelman, Zivin, Terplan, Mhyre, Dalton; Obstetrics and Gynecology, Vol. 132, No. 5, November 2018
- Improving Medicaid in Texas, Texas Medical Association Journal, 10/23/18
- 10 cities with the highest uninsured rates in the nation: 8 are in Texas, Ayla Ellison, Becker’s Hospital Review, 10/11/18
- “Rural Hospital Sustainability: A Worsening Situation, David Mosley and Daniel DeBehnke, MD, Navigant—February 2019
- “Minding the Health Care Gap”, Leanne DuPay, Travis County Medical Society Journal, March/April 2019
- Expand Medicare incrementally:
- “The best course for providing health care lies between entitlements and options, Scott Crocker, MD, (heart surgeon in Abilene); Texas Medical Journal, 3/5/18, Tex.Med.2018;114(3):12
- Target high users for special care and
- Make timely, efficient behavioral health care available for all
- “We Must Address Social Determinants of Health”, Jennifer Frank, MD, Physicians Practice, 4/26/19
- Cerner unveils social determinants of health collaborative, Jackie Drees, Beckers CIO and IT Report, 5/29/19
- “To Improve Texans’ Overall Well-Being, All Texans Must Be Able to Choose Well”, John Carlo MD, Texas Medicine, February 2018, Tex Med 2018;114(2):6
- “Collaboration with Community Aims for Better, Smarter, Healthier Care”, Frederick Cerise, MD, MPH, President and CEO, Parkland Health and hospital System, Lifeline: Parkland Foundation Newsletter
- Diagnosis Poverty: A New Approach to Understanding And Treating and Epide mic, Marcella Wilson, aha! Process, 2017
- Bridges to Health and Healthcare: New Solutions for Improving Access and Services, Ruby Payne PHD, lead author, aha! Process, 2014
- Make medical records readily communicable nationwide:
- “5 ways blockchain could improve healthcare”, Mackenzie Garrity, Beckers Hospital Review, 2/27/19
- “Healthcare Blockchain System Using Smart Contracts for Secure Automated Remote Patient Monitoring”. Griggs et al, J Med Syst 2018 Jun 6;42(7):130.
- Aetna, Ascension join blockchain pilot project to addresss provider data issues, Beckers Health IT Review, 12/3/18