Category Archives: Health Care Quality

Revolutionizing Heart and Vascular Care

At UNC Health Care, we are always looking for new and innovative ways to serve our patients. One way we do that is through partnerships and collaboration. I am proud to say that, through our partnership with UNC REX Healthcare, we recently opened the doors of the new, state-of-the-art North Carolina Heart & Vascular Hospital on the Raleigh campus of UNC REX.

North Carolina has the 12th highest incidence of heart and vascular disease in the country. We lose about 18,000 people annually from heart disease. At the same time, the population continues to grow, increasing the demand for quality health care providers.

The 114-bed hospital is staffed by leading physicians in Wake County, and is now the hub for a premier heart and vascular program in the Southeast. Since we are an academic medical center, we also bring in medical students from the School of Medicine who are training in interventional cardiology and vascular surgery. This not only helps advance the teaching mission of the medical school, it also provides a closer connection to the research and advanced treatments provided by the Medical Center in Chapel Hill.

Since all of UNC REX’s heart and vascular services moved into this new facility, there are plans to improve and repurpose vacated space on its main campus to improve patient care. For example, part of this space will be converted into a behavioral health zone for patients being treated in the hospital’s emergency department – fulfilling a critical need in Wake County.

For more information on North Carolina Heart & Vascular, click here.

Improving Mental and Behavioral Health in Our State

UNC Health Care is committed to caring for all patients, including those with mental and behavioral health issues. As our population grows, the demand for beds and dedicated inpatient psychiatric care continues to rise.

In Wake County, more than 65,000 people suffer from a serious mental illness. Yet, from 2012 to 2015, we were one of just three states to decrease behavioral health spending each year. More than half of our counties are without a psychiatrist, and only 35 percent of our hospitals have a psychiatric unit.

Regular hospitals and health facilities often don’t have the time or resources necessary to help treat and provide services for those with mental health, behavioral and substance abuse problems.

At UNC Health Care, we are taking steps to address this growing need. At UNC REX, we have worked to improve our triage process in the emergency department to ensure that mental health patients get the care they need as quickly as possible. We also recently expanded UNC WakeBrook, a facility in Raleigh designed to care for those with mental health, behavioral and substance abuse problems.

At the federal level, we are pleased to see policymakers making mental and behavioral health a priority as well. Late last year, the 21st Century Cures Act was signed into law.

Among many other things, the Act strengthens laws mandating coverage parity for mental health care and provides funding to help increase the numbers of psychologists and psychiatrists.

The expansion of WakeBrook and the 21st Century Cures Act are steps in the right direction, but there are always opportunities to do more. We will continue working closely with public health officials and legislators to provide better care and better access to our state’s mental and behavioral health patients.

 

Today’s Research Is the Key to Tomorrow’s Treatments

At the UNC School of Medicine, our focus is on one thing: improving the health of patients across the state and the nation. We are nationally recognized for providing outstanding care and serving countless people across the state, day in and day out. We also earn national recognition for our research. In fact, this month alone, the National Institutes of Health (NIH) awarded researchers at UNC SOM three grants totaling more than $179 million. These investments in research are also investments in people, because they lead to better care for patients.

For instance, Baby Connectome Project (BCP) will help scientists to better understand what is needed to support brain development in the critical first years of life. This $4 million grant awarded to UNC SOM and the University of Minnesota will enable researchers to track the circuitries of the brain and its development from birth through childhood to uncover factors contributing to healthy brain development.

The UNC SOM was also included in a $157 million grant to launch Environmental influences on Child Health Outcomes (ECHO). This initiative aims to investigate how exposure to environmental factors in a child’s early development, from conception through early childhood, can influence later health outcomes. This means understanding how air pollution, stress and other factors can affect the biological process, with the goal of ensuring that every baby will have the opportunity to lead a healthy life.

Finally, the UNC/Emory Center for Innovative Technology, or iTech, will allow researchers to develop ways to address barriers to HIV care. The $18 million in funding will help researchers to target 15 to 24-year-olds at risk of or currently living with HIV through mobile apps that are intended to increase HIV testing. This means developing electronic health interventions for those who test positive for the virus, ultimately leading them to care and antiretroviral therapy.

These are all some of our most challenging health care issues. Thanks to the support from NIH, our researchers are making headway in finding the underlying causes – and potentially finding cures – for these challenges.

For more information about the Baby Connectome Project, click here.

For more information about ECHO, click here.

For more information about iTech, click here.

UNC Health Care Again Ranks Among Best Hospitals in the Nation

At UNC Health Care, our vision is clear: to be the nation’s leading public academic health care system. We are committed to providing North Carolinians with the highest level of care. We are continually looking for new and innovative ways to improve the quality of care that we provide for patients across our state. And we are clearly making progress. I am pleased to say that the recently released U.S. News & World Report 2016-2017 Best Hospitals rankings confirm our commitment to quality and excellence.

UNC Hospitals was nationally ranked or recognized as high performing in 10 clinical categories listed in the U.S. News & World Report 2016-2017 Best Hospitals rankings. Four of our specialties were ranked highest in the state.

Across the state, our system performed well. UNC Hospitals, UNC REX Hospital and UNC High Point Regional Hospital ranked No. 2, No. 10 and No. 16, respectively, in the Best Hospitals rankings for North Carolina.

UNC Hospitals ranked higher in eight clinical categories compared with the 2015-2016 rankings, including Urology, Cancer, Diabetes and Endocrinology, Nephrology, as well as Gastroenterology and GI Surgery.

I will elaborate on just how extraordinary this recognition is. U.S. News & World Report rankings are among the most prestigious of their kind. This year’s rankings began with a pool of 4,667 hospitals representing virtually all U.S. nonfederal community facilities. Only 153 hospitals in the United States, across all 16 specialty categories, performed well enough to be nationally ranked in one or more specialties. The scores are established on the basis of issues like severity-adjusted mortality and patient volume as well as on the hospital’s reputation among specialist physicians.

As UNC Health Care continues expanding across the state, we have remained steadfast in our core beliefs and values. This unwavering commitment to strive for excellence is what enables us to provide the best possible care for the people of North Carolina. And these scores are a clear indication that we are making tremendous progress on the goals we have set.

For a full list of U.S. News & World Report 2016-2016 Best Hospitals rankings and UNC Hospitals recognition, click here.

The State Of Things: My View on Health Care in America

I recently was interviewed by Frank Stasio on WUNC’s “The State of Things.” We discussed the health care challenges our country faces, including gaps in mental health and preventive care, among others. I also discussed some of the myths about health care in our country and explained how UNC Health Care is working with others to provide high-quality affordable care and to train the next generation of physicians.

Listen to the full interview here.

State Snapshots from the Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality (AHRQ) recently released its 2011 State Snapshots, which provide state-level performance overviews on treating cancer, diabetes, maternal and child disorders, heart disease and other diagnoses. According to the data, North Carolina performs well in areas like preventative care and acute care. Quality of hospital care also remains on track with national averages. In clinical areas, our state has improved respiratory disease and cancer care since baseline year data was collected. You can view North Carolina’s full state snapshot here.

I am proud of North Carolina’s performance in these categories and I commend the work of our state’s providers. However, there is still much to be done to improve the quality of and access to care across our state. For instance, we lag behind other states in diabetes and heart disease measures. According to the Centers for Disease Control, nearly 30 percent of North Carolinians were considered obese in 2010 – making them more susceptible to diabetes and heart disease. As the needs of our state increase, the care we provide must change to meet the growing demand for services.

At UNC Health Care, we are working with other organizations and providers across the state to meet the growing demand for services and care. By improving access to quality public health services, training the next generation of physicians and conducting research, we hope to mitigate the challenges our state continues to face. The AHRQ snapshots provide a helpful benchmark for improvement as we move forward.

Annual North Carolina Leadership Dinner

Raleigh, NC

Yesterday evening, I spoke at the North Carolina Leadership Dinner as part of the 2011 Emerging Issues Forum, presented by the Institute for Emerging Issues at North Carolina State University. Each year, the Forum brings together leading thinkers and decision makers to foster bigger and better ideas for innovation and improvement of our state and nation. I have included my remarks below.

I have been working on improving the public’s health for almost 35 years. And as I look out in the audience, I know that many of you have been in the trenches for as long, or longer than I have.

We are fortunate in this state – and especially fortunate in this region – to have access to some of the best medical care this country has to offer. I arrived in this state a little over a decade ago. The decisions that our state’s leaders made long before I arrived, and the teamwork with which they approached the challenge of building modern health care in North Carolina paved the way for all that we enjoy today.

But through the years, there have been several activities that I am especially proud of:

From fluoridating the public water supply in my home town, Birmingham, Alabama, to starting Medicare’s efforts to publish information allowing quality comparisons across the Nation’s hospitals.

From adding “Prevention” to the name of the CDC, and making prevention a practical reality in the Nation’s health system, to creating the NC Institute for Public Health, the outreach and service arm of UNC’s school of public health.

And from building the NC Cancer Hospital to implementing the new University Cancer Research Fund, I am deeply proud to have been involved in each of these efforts – but I am by no means claiming exclusive credit for any of them – they were very much team efforts. These achievements required lots of people, many organizations and institutions, working together to do challenging and important things to improve the public’s health.

For most of these years, I also have been working on reforming the American health care financing and delivery system – beginning with my work as a lower-level White House staffer for President Reagan.

I did the staff work for his health reform package from his State of the Union speech 28 years ago. I am sure you all remember it, right?

No, you don’t, because it did not get enacted.

Many health reform efforts – by many administrations – over many decades – went nowhere.

Of course, last year President Obama and the Democrats in Congress passed the Accountable Care Act. And promptly, the Republicans began the repeal effort.

It is too early to say how all this will turn out – and it is not my purpose this evening to speak in favor of or against the ACA.

Many of you know this, but let me be plainspoken. I have been appointed to political positions by three Republican presidents – Reagan, Bush 41 and Bush 43. At the same time, Nancy-Ann Deparle and Don Berwick – the key people on health reform for President Obama – are close friends of mine.

So I believe I have a reasonably balanced perspective on health reform.

You do not need me to handicap what’s going on in Washington – there are plenty of others who are doing that – take your pick.

But I will make one point – the various activities I mentioned at the beginning of my talk this evening – things I’m proud of being a part of over the years – they were team efforts – made possible by broad-based, bipartisan collaborative work.

We very much need a team effort to fix health care in America – and here in North Carolina.

Of course, there are limitations to what a single state can do, acting alone. But that should not be an excuse for total inaction.

That’s my message this evening – to all of us here convened by Governor Hunt and the Emerging Issues Forum – all of us, consumers and providers, business leaders and elected officials, rural and urban, Republicans and Democrats.

I believe the single biggest thing holding us back from thoroughgoing reform of our health care system is that we each believe that somebody else needs to change, needs to reform. If only they would do it, then all would be well.

I think we are the collective victims of our concerted efforts to blame someone else. Or to believe some things that just aren’t true.

What I am going to do with the remainder of my time this evening is empower us to rethink our long-held assumptions, and to move us from our comfortable, but mistaken, positions. This will guide us toward a team effort to build a much better American health care system, starting here in North Carolina.

So, here is my list of the top things we know for sure about health care – things that are not true.

1. The American health care system is the best in the world.

For all the good it does, it really needs a major overhaul. I believe the oft-reiterated slogan that our country’s system is the “best in the world” is evidence of a desire to keep everything as is. I am an “American exceptionalist” too, and I know that some of you hate international comparisons – but it is simply undeniable that on average, outcomes of care in the US are not as good as average outcomes in many other industrialized countries. This is mostly because of our inability to close the disparity in the health outcomes for certain ethnic or racial minorities.

The international comparisons are not looking at the best each country has. They are comparisons of where things are on average – from top to bottom. And our bottom is what pulls us down. These people spend large parts of their lives outside the health care system. They haven’t seen the inside of a doctor’s office for years. They know only the ER at a hospital as their usual source of care. When it comes to a national average, they get equal billing with those who take advantage of the best we can offer.

2. Everybody eventually gets the care they need.

Repeated studies have shown conclusively that there is a huge cost to American society of “uninsurance” – people seek care later, have worse illnesses and worse outcomes. And we have the crazy quilt of cross subsidies – paying customers pay much more to cover the cost of uncompensated care – for UNC Health Care, which includes Rex Healthcare here in Wake County, that’s $300 million this year.

3. Almost always, the quality of care people get is very good.

Many researchers, especially Dr. Beth McGlynn at RAND, have shown that far too commonly, people do not get the care they need – and others like the Institute of Medicine have shown the harm done in the processes of care because of the lack of attention to patient safety. I chair the board of the National Quality Forum, and we are working with all parties at interest to measure and report results and then to drive vast improvements in care quality.

4. The cost of care in America is not really a problem. It is a clean, non-polluting industry that employs millions of people. And at a time when the economic problem is “jobs, jobs, jobs,” health care is one sector where employment continues to grow.

Health care now represents 17 percent of our economy, which is far more than any other country. At a time when we are worried about our competitive position in the world economy, this has to be a concern. And the Medicare actuary has just said that health reform is going to add to aggregate health spending.

Let me be even more emphatic – proposals for health care reform that do not take cost control seriously should not themselves be taken seriously. Indeed, that is a major shortcoming in last year’s legislation.

5. If you like your care, nothing about it will change

This is a line often used by President Obama. Unfortunately it is one of the most hurtful of these mistaken ideas. Because almost everything about American health care must change if we are to be successful in overhauling it as I am suggesting.

We need to redesign care in fundamental ways, to create coordinated care across primary and specialty doctors and others, so that each of us has a “patient-centered medical home.” As I hope you have heard, that is what we are doing in a very innovative pilot medical office with Blue Cross Blue Shield of North Carolina.

This initiative, if successful, could help avoid putting consumers in the middle of health insurance conflicts.

Let me say a bit more about health reform. The news media focuses on conflict in the health care debate. That focus keeps attention from an emerging Washington consensus on health care. In watching the back and forth between Republicans and Democrats, we pay no attention to what they agree on.

They agree that on the fact that future government will take less of the financial risk attributed to growing health care costs. Yes, they disagree about who should bear the risk instead, and how that risk should be borne. Democrats in Washington prefer solutions that put more risk in the hands of health care providers, and Republicans want individuals to deal with more of the risk themselves. But we should not let this back and forth cloud the reality that both parties are telling us that the government will take less of the risk. Both parties are saying that some parts of the health care system will have to change in the future.

Let me say again – we very much need a team effort to fix health care in America – and we need to do that right here in North Carolina.

I have tried to tell you the truth, about a series of long-held and unfortunately mistaken ideas about health care. You might be sitting there frustrated, and even disappointed with what I have told you.

I am hoping that as I went through some of the myths about our health care system, many of you thought, “Well, Bill, you’re right.”

The problem is that the myths don’t go away. Ours is a free country, and everyone is entitled to believe what he wants. And unfortunately, I think the average North Carolinian is not yet on board to face the challenges ahead.

There is a vast gap between the experts and the public on health care. For example, there is a consensus among those who do research on our health care system that much care that is delivered is unnecessary. But that is not the view of the average American. When surveyed, 67 percent said they do not get the tests and treatment they need. Only 16 percent said they received care that was unnecessary.

This divergence of views has had a powerful impact on what happens when health care experts suggest ideas to politicians about how best to go about dealing with lowering costs. By going along with the experts’ assumption that we have unnecessary care, those politicians created an opportunity for their opponents to reach the 67 percent who think they do not get the tests and treatments they need. And that, I would suggest, is how the term “death panel” gained such potency.

The reason we continue to over-treat is three-fold:

  • Patients demand more
  • Most health care is paid for on a fee-for-service basis, so the more you do the more you make
  • Our medical liability system makes providers reluctant to say no to patients.

Those who expect individual consumers to make more cost aware choices also have reason to be disappointed. Only 22 percent of Americans say they have ever asked about cost when making health care choices.

As someone who has worked very hard to create information that would allow comparisons of health care providers, I find it disheartening to learn that 70 percent of Americans believe there are no big differences across health care providers. If you don’t believe there is a difference, you will never want to look for anything better.

In a free market, the consumer rules. At this point, the consumer is not open to much of what the experts recommend.

As we try to rally the citizens of North Carolina and the nation to take on the challenge of health care overhaul – a major problem is this disconnect between the “experts” and the “average person.” I confess to being a health policy wonk – and we “experts” have long been concerned with the issues on my list above.

But the typical hard working North Carolinian – who today may hold down two jobs and surely wants to be responsible – all too often cannot afford the co-pays and deductibles if he has a sick child, especially one with a chronic illnesses.

That is what real people are worried about. And we owe it to them to come together to work on these real issues with vigor and determination, not just hunkering down with our long-held positions and slogans.

Our state has long had a proud record of innovation and leadership in health and health care. With the ideas and energy that you and the Emerging Issues Forum speakers have brought to this conference, I am very hopeful.

Yes, I mean those words. I am hopeful, but they can surely sound like high-minded platitudes. It is not enough for us simply to say “let’s work together.” We actually have to do it.

There is an old Greek proverb: “A society grows great when old men plant trees whose shade they know they shall never sit in.”

Friends, young or old, let’s go out – together – and plant some trees. With teamwork, we can do great things for North Carolina.

Debate over mammograms reveals need for confidence in health care

This week we have had a disquieting reminder of one of the challenges we face in overhauling health care in America the public are deeply distrustful of experts.

The US Preventive Services Task Force an appointed body of leading clinicians and scientists issued a new recommendation of when women ought to have mammograms. Because it differed from what had previously been the advice, and especially because it differed from what millions of people thought they knew to be true the new guidelines were roundly criticized and scorned. By week's end, the USPSTF had tried to clarify what they were saying, and then the US Secretary of Health and Human Services asked the American people to disregard the recommendations altogether.

Not a pretty sight, especially for those who believe that we can improve care and make it more efficient and effective by carefully targeting what is done for individual patients.

I am one of those true believers in health services research and guidelines for the delivery of care comparative effectiveness research, as it is called these days.

I don't know what the right advice is for women regarding mammograms. But one thing I do know if this whole effort is going to work, we have to get to a place where the public has confidence in the experts else we might as well quit trying.

Maybe this is all due to our American individualism or maybe it is because so many of us learned to question authority. Whatever the explanation, it is not helpful to our efforts to construct a more rational health care system, guided by rigorous research and the consensus of the leading scientists and clinicians.

Until we solve this conundrum, we might want to slow down on our promises of health cost savings from comparative effectiveness research.

Health Reform – an Update

Several people have asked me in the past few days for my perspective on what's happening to health reform in Washington.

For what it's worth, here goes

Congress is in recess until Labor Day, and they are back home having lots of meetings with their constituents. President Obama is also hosting events almost daily to discuss health reform with the American people.

We have a governmental system that is chaotic and messy at times and this is surely one of them. Remember the quote about making laws is like making sausage ¦

Several points I'd make

1. Although President Obama won handily (53 percent to McCain's 47 percent), there are a lot of Americans who did not vote for him. So it should be no surprise that many of them are showing up at events and town hall meetings and voicing their opposition to whatever the Democrats and the Obama Administration are working toward. The fact that politics has intruded is shocking to some people, I know, but that's the American way.

2. We still badly need to reform the American health care system and as hard as this public policy and political process is, we need to press ahead as a nation.

3. As we deal with the all too familiar problems of the cost of health care, the lack of access due to uninsurance, and the quality and safety of health care in America, a lot is up for grabs. A few weeks ago it seemed like the Congressional leadership were just going to steamroll the process and enact thoroughgoing reform of the entire system. Now the sheer magnitude of all this is scaring a lot of people, especially at a time of such great economic uncertainty.

4. Proposed reform that does not take seriously the need to constrain cost growth should not itself be taken seriously. And as much as I support prevention (and I do, I put Prevention in the name of the CDC), it likely will not reduce health care expenditures though it will make us all healthier. And as much as I support Health Information Technology (and I do, very much), it is likely to add to costs for the foreseeable future, not save.

5. We need to have a serious discussion as a nation about end of life care and we are beginning that conversation now. We waste (yes, that's the right word) a huge amount of resources there. But we as a nation don't want the government making these decisions like taking your mother off the respirator. My sister and brothers and I had some tough decisions to make as our mother and father were gravely ill, and we made them. But not the government.

6. But critics of the President are crassly scaring the American public with this issue and we need to counter their fears with an honest conversation about the limits of medical care, and help patients and families with those tough decisions.

7. There are some things the government does right and the Medicare program is one of them. We should be proud of it. And I am proud to say that for several years in the 1980s I was responsible for administering it. But it is not a model for the rest of the health care system it is outmoded and frozen in time, tied to a payment system of fee for service that does not make sense for doctors or patients.

8. That is one of the risks of the public plan option that is being debated right now can a government plan innovate and be creative over time?

9. Also, Medicare pays rates to doctors and hospitals that are below the actual costs of delivering that care. A new public plan, if linked to Medicare, would have tremendous clout in the market place institutions like ours would almost certainly have to take whatever rates they offered, even if greatly below our costs, which would surely worsen the crazy quilt of cross subsidization that we now have in health care finance in our country.

10. One of the ironies right now is that many in Congress are insisting on the public plan option because of their faith in the government's ability to run the program, yet many of the same Members are urging that a new independent body MedPAC enhanced be set up to make decisions and oversee the entire system, because they don't trust the regular governmental agencies (like HHS and CMS) and processes (like the Congress) to manage things well.

11. So ¦ where are we? I think the Senate Finance Committee proposal, which is yet to be completed, will be the plan that ultimately holds sway. Yes, there will be some who say it is too conservative, and others will say that it is too liberal (whatever those words mean in this complicated area). But I believe it is likely to pass this fall, surely amended many times. The political stakes are just too high for the President and the Congress they cannot allow failure.

12. So I'd suggest you keep your eye on Senator Baucus and his colleagues on the Senate Finance Committee, and try not to get too distracted by the sound and fury around the whole process.

13. Will such legislation be good for the country? I very much believe so. But this is woefully complicated and it needs to be done right. So taking a little more time is not a bad thing.

14. And what will such legislation mean for UNC Health Care? It's way too soon to answer that question with any finality, but given our huge problems with the uninsured, we would have to be better off, at least in the short and medium term, if those now uninsured are covered. The longer run is harder to predict because the risk is as costs rise, and they inevitably will, will our payments be cut so much that we end up worse off? Time will tell.

15. And in the meantime, we have recently launched an effort to redesign how we deliver care, so that we can be one of the places that people point to as an institution that delivers top quality care in an efficient manner, with lower overall costs. I very much believe that is do-able, but it won't be easy. It will stretch us as an institution, requiring our doctors and hospitals and others to work together in creative ways that we haven't even begun to try yet. But we must I want us to be a part of the solution, not a part of the problem.

More to come ¦ stay tuned.