AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
JEFFREY GOULD: I’m just going to say a few things so maybe we can have a couple of questions also. What is the California model or the California CPQCC model? I think there are three things and one thing is that we’re really focusing on both obstetric and neonatal health, which is--which is really unique. I mean, it’s usually, you know, you pick one or you pick the other, but if you’re going to improve prenatal health you really have to focus on both. The second thing that’s kind of unique and you may have missed it because of the--the time frame, but a lot of the obstetrical indicators are measured on a very low risk population, so the strategy of using--which I think is a pretty brilliant strategy, because what it does is it gets rid of a lot of the very technical risk adjustments and it also--the super low risk population is, in terms of bang for the buck, that’s the big delivery population.
So if you have a low risk population that is huge and you can demonstrate problems in that, it has a lot of impact in that, you know, we’re part of that low risk population. And so when you start to show that that population is having problems as well as the higher risk populations, it has a lot of political impact, I think a motivational impact. But the biggest deal I think is this hold in the CPQCC model, is to use a business quality improvement model rather than the traditional public health intervention model. The traditional public health intervention model, you know, you have a teen pregnancy program, you’ve read the literature, you get your group together, you put together a model program, you run it out, you decide on, you know, your database to see what happens and, you know, three or four years later, you know, you assess this or maybe every year you do some process, but it’s the kind of thing where--where the focus is on developing this model which you think is going to work out and then you kind of go and use your data to--to make sure it didn’t work out.
The quality improvement models is really very, very different from that and what you do there is you--you really--you--you get an issue and you develop long-term and short-term goals and then what you do is you--and you get your intervention strategies together and then you get together a database that’s very minimal. It only has really the outcomes you’re interested in and the risk adjustors and some of the process things that could--that could delay you, so it’s a very--it’s a very specific database. And a lot of the energy in this model is building this database, because this is the database where you have to really say, we’re looking at this because, you know, and you’ve got to say why, and we’re risk adjusting because and you have to say why these risk adjustments. And here are the key processes that are going, you know, if this thing falls short in six months, because of these not happening, so the whole thing is very focused towards movement forward.
And then one of the things you do in the--in this quality improvement model is it’s not seen as a five year thing, it’s seeing as a rapid cycle improvement, so you break the thing down into these very rapid things that are--that--that you’re monitoring all the time, so, like, in a teen pregnancy thing that--one of the things you have to do is you have to get teens into the project, so that becomes a short-term goal. And then you work on that, you know, you don’t wait for a year, you know, like, it may be within three months we’re doing this and six months--and then in six months, if you haven’t met your--your objective, you have to say, “What’s--what are we--are we not outreaching enough? Are we not doing this? Are we not doing that?” And then you adjust it and you do it over again, so this whole idea of a quality improvement approach is--is quite different in that it’s short term dynamic and it goes around and around very rapidly, but the beauty of this is that it makes you re-think what you’re doing and re-assess what you’re doing in--in a--in very rapid time period.
It also--these rapid cycles also have the--the--what else that they do is that they tend to motivate the project. And I know you’ve all been involved with projects and you start them and you don’t know what’s going on for a long time and people are working, but the high level of motivation that you get when you see the numbers coming back, sometimes it’s, you know, it’s--it’s--it’s just not there, but with the quality improvement model, these rapid cycle things, you get immediate feedback and you know where you’re going and it’s very--it’s very encouraging and it adds a lot of motivation. So one of the things that we’re trying to do as we--as we look at other public health areas in MCH in California is to see, you know, what would happen if we--if we tried to use this business oriented quality improvement model versus the traditional public health model, so that’s why--in a few minutes it’s hard to explain. The other thing that we’re doing is that--is this whole notion of value, you know, this whole--well, what is bottom up value?
Bottom up value is something that’s driving us and we’re not driving--we’re not trying to reduce maternal mortality, you know, by going out and saying dead mothers are bad, everybody knows dead mothers are bad. No one wants to have dead mothers. What we’re trying to do is--we’re trying to--but that’s a public health model, you know, we’ve got to reduce this bad thing. We come at it a different way, we’re saying, we have a tool kit. We know you’d like to go to bed thinking you’ve done a great job and we know it’s hard to do a great job with limited funding, with high risk mothers, with this and that, long hours, it’s hard to do this. We’re going to develop a tool kit that is going to help you go to bed saying, “Well, I have done a great job, fewer mothers are going to die, fewer kids are going to get complications.” And this is the kind of value that we’re trying to build into this process so that--so that we get practitioner buy-in and institutional buy-in, not because the goal is great, but because the--the institution and the--and the--the institution and the practitioner get value from this process--from this process. I--I--I know this is very rapid, but I--but I--I--I wanted to--‘cause these are different--this is a slightly different way of looking at our mission, addressing our mission, so I wanted to stop now so there’d be time for a few questions.
UNKNOWN SPEAKER: Yes, Dr. Gould, you mentioned that the--you were using the model in areas where there are known interventions, known (inaudible) interventions and it may be that there’s a long enough list of those that you can continue with that, but one other potential use of a (inaudible) collaborative such as you’re describing is to develop interventions. I was wondering if you’ve considered that.
JEFFREY GOULD: Yeah, we’re at five years now and the interesting thing is that what’s starting to emerge is the notion that we should perhaps be doing randomized trials. That there are some areas that we just don’t know. And unfortunately there aren’t a lot of--one of the problems we run into is there’s not a lot of, you know, interventions that have been shown to really work, so if you stick to that definition you’re really limited. So then the next thing is you can kind of benchmark and you can say, “We’re going to go after something and we know that 25 percent of the units are doing really well, so let’s go and benchmark and see what they’re doing,” but then you come to the point that, you know, you’ve got all these people out here, you’ve got a question, why not do a randomized trial and that’s just where we’re at. And again, this could be used in a network of black infant health programs, in a network of teenage programs, so it’s not that--although we’re kind of, like, you know, we’re working more in the care dimension than in the risk reduction dimension for this particular examples that we’ve presented that we think that this kind of approach really could work--really could work. And what I would do is if you had a network of let’s say teenage prevention programs, that from the get go they would start benchmarking and saying, Why are you different for us? What are the problems that held up our gaining this little short term objective, you know, and--and then the groups get together and they say, “Well, we solved that one by doing YMCA,” you know. Yeah?
UNKNOWN SPEAKER: Didn’t hear any of you mention much from other (inaudible) holders, where--where do health plans and payers fit in, I gather a business troop is there and what about advocates and folks who are vigorously interested in finding and publicizing (inaudible) and healthcare systems. How do they deal with this information?
JEFFREY GOULD: We haven’t had a lot of--the advocate--this hasn’t become politicized in terms of advocates. In fact, Pacific Business Group on Health made us go public on the web. Their website is so difficult to--to use, I mean, really, it’s hard to do a hospital-to-hospital comparison, and maybe that was political, so there was more smoke there than, you know, than--than fire. You know, it’s--the nice thing about good--good medicine, obstetric and neonatal, all good medicine is cheaper medicine. And everybody realizes this, so there’s tremendous incentives on the parts of the insurance, like--like Blue Cross loves this program, because they know that--that people in this program are actively working to reduce maternal mortality and--and neonatal mortality and in--and when you’re working to reduce mortality it’s also morbidity and morbidity is costly, so--so the private insurers really push hospitals joining us. We--we have a lot of input on that.
EMMETT GONZALEZ: I just want to make a quick remark and I think part of Dr. Shabbir’s slide was the preconception care and interconception care, depending on which model you use, but we want to be able to tie that into the morbidity issues so that we use the preconception model, which by the way some of you may be interested, if in case you haven’t heard, in June CDC and Prevention has a workshop on preconception care, that we can start addressing some of the elements that are associated with these morbidities that I talked about mostly in-hospital problems, but they’re really associated with before.
UNKNOWN SPEAKER: (Inaudible) you know, certain medicine is cheaper medicine, but there’s not one cost (inaudible) by the state, there’s one by your foundation founders, other partners?
JEFFREY GOULD: The costs are enormous, absolutely enormous to get this thing rolling. We started off with--Packard Foundation gave us seed money with a five year--with a five-year--diminishing five years. We charge a very modest fee, it’s about $4,000 a unit. And that may sound like a lot to us, but I can tell you that a CEO of any hospital wanting a list of anything, if they could get it for $4,000 it’d be the biggest deal. They talk about it for the next 10 cocktail parties, so--so to practitioners and public health folks, it sounds like a lot of money, but to CEOs it’s pretty trivial, but we still have trouble, you know, getting it. So at this point and initially--so we had Packard Foundation to get us started and we have membership fees that are fairly modest. State MCH pays for our data center space, so we have a huge space and our equipment, etcetera.
Stanford University ’s Children’s Health Initiative has put in a lot of money for these--these collaborative meetings are really expensive. Although people bear their own costs, amazingly, it’s very expensive to put on these meetings. We have workshops--because our approach is, like, all state, everything has to be very inexpensive, so our workshops are only, like--like, $100, $150, which is, again, for an all day workshop. We don’t--it costs us much more than we’re charging, but we recoup a little bit that way. We have--CAN has been supporting our web cast, so I don’t know if I’ve talked about web cast, but we’ve been doing web casts to reinforce these principles on the various tool kits and also the web cast is split, so half of the web cast is a case study that’s working from a particular hospital on a topic and then the other half is kind of didactic and the web casts are being supported by California Association of Neonatologists. I think at last count we were about 100,000 under, you know, kind of like sustainability, but fortunately we had a--a little bit of research and stuff that made up that gap. So our real goal is to--is to become sustainable, but you have to put a lot of money in this, I mean, we built a whole data center and--and that’s very--that’s a pretty expensive proposition as well.
UNKNOWN SPEAKER: What is a sustainable (inaudible)?
JEFFREY GOULD: I--I don’t know, you know, it’s--I--I--I was going to bring that in. I--I decided not to, it’s a lot, it’s a lot.
UNKNOWN SPEAKER: When you get information from obstetric charts, do you have a master time index for tracking?
JEFFREY GOULD: At this point there’s--at this point tracking is not an, you know, it’s not something. That would probably be in the future. What we’re using is--what we’re using is the abstracted--at this point we’re using, for obstetrics, we’re using the abstracted discharge summary, that’s the--the universal billing form and that has to be validated. We’re hoping that what--what will happen is that we’ll bring in obstetricians into this kind of model using data that’s already collected and then--then once they buy in they’ll say, “Hey, wait a minute, we don’t like this. We want to collect our own. We want to have our own database. We want to adjust for this that you guys didn’t think of,” but we have to build value and we’re hoping to be able to build value by giving them risk adjusted reports based on OSHPED data that’s been worked on as a first step.