Douglas E. Hough

Outcomes of a program in business education for physicians and other health care professionals.

Background We sought to determine the expectations that graduates of one business of medicine program had upon enrollment and to ascertain fulfillment of those expectations after completion, as well as the extent to which participating in the program improved business skills and led to advancement in office practice or career development. Methods A postal mail survey was conducted of graduates of The Johns Hopkins Universitys Business of Medicine Program, a yearlong, four-course certificate program to educate midcareer academic and nonacademic physicians and other health care professionals about fundamental business practices and their application to health care. Results Surveys were sent to 285 graduates, and responses were received from 136 (48%) of them. Most respondents expected the program to expand their management skills, to enhance their knowledge of marketplace trends, and to advance their careers. These results were not correlated with respondents’ age, sex, or profession (ie, physician, nonphysician). More than 87% of respondents agreed that their overall expectations had been fulfilled by the time they completed the survey. Participants noted, however, that several expectations were unfulfilled upon replying to the survey. Conclusion Programs designed to educate physicians and other health care professionals—in private practice, academia, or industry—about the business aspects of medicine can be effective but need to be designed carefully to integrate business theory and application to the medical setting.

Applying JIT Principles to Resident Education to Reduce Patient Delays: A Pilot Study in an Academic Medical Center Pain Clinic

OBJECTIVES This study investigated the effect on patient waiting times, patient/doctor contact times, flow times, and session completion times of having medical trainees and attending physicians review cases before the clinic session. The major hypothesis was that review of cases prior to clinic hours would reduce waiting times, flow times, and use of overtime, without reducing patient/doctor contact time. DESIGN Prospective quality improvement. SETTING Specialty pain clinic within Johns Hopkins Outpatient Center, Baltimore, MD, United States. PARTICIPANTS Two attending physicians participated in the intervention. Processing times for 504 patient visits are involved over a total of 4 months. INTERVENTION Trainees were assigned to cases the day before the patient visit. Trainees reviewed each case and discussed it with attending physicians before each clinic session. PRIMARY AND SECONDARY OUTCOME MEASURES Primary measures were activity times before and after the intervention. These were compared and also used as inputs to a discrete event simulation to eliminate differences in the arrival process as a confounding factor. RESULTS The average time that attending physicians spent teaching trainees while the patient waited was reduced, but patient/doctor contact time was not significantly affected. These changes reduced patient waiting times, flow times, and clinic session times. CONCLUSIONS Moving some educational activities ahead of clinic time improves patient flows through the clinic and decreases congestion without reducing the times that trainees or patients interact with physicians.

Using process analysis to assess the impact of medical education on the delivery of pain services: A natural experiment

Background: The medical, social, and economic effects of the teaching mission on delivery of care at an academic medical center (AMC) are not fully understood. When a free-standing private practice ambulatory clinic with no teaching mission was merged into an AMC, a natural experiment was created. The authors compared process measures across the two settings to observe the differences in system performance introduced by the added steps and resources of the AMCs teaching mission. Methods: After creating process maps based on activity times realized in both settings, the authors developed discrete-event simulations of the two environments. The two settings were comparable in the levels of key resources, but the AMC process flow included three residents/fellows. Simulation enabled the authors to consider an identical schedule across the two settings. Results: Under identical schedules, the average accumulated processing time per patient was higher in the AMC. However, the use of residents allowed simultaneous processing of multiple patients. Consequently, the AMC had higher throughput (3.5 vs. 2.7 patients per hour), higher room utilization (82.2% vs. 75.5%), reduced utilization of the attending physician (79.0% vs. 93.4%), and a shorter average waiting time (30.0 vs. 83.9 min). In addition, the average completion time for the final patient scheduled was 97.9 min less, and the average number of patients treated before incurring overtime was 37.9% greater. Conclusions: Although the teaching mission of the AMC adds processing steps and costs, the use of trainees within the process serves to increase throughput while decreasing waiting times and the use of overtime.

Case Study: Johns Hopkins Community Health Partnership: A model for transformation

To address the challenging health care needs of the population served by an urban academic medical center, we developed the Johns Hopkins Community Health Partnership (J-CHiP), a novel care coordination program that provides services in homes, community clinics, acute care hospitals, emergency departments, and skilled nursing facilities. This case study describes a comprehensive program that includes: a community-based intervention using multidisciplinary care teams that work closely with the patients primary care provider; an acute care intervention bundle with collaborative team-based care; and a skilled nursing facility intervention emphasizing standardized transitions and targeted use of care pathways. The program seeks to improve clinical care within and across settings, to address the non-clinical determinants of health, and to ultimately improve healthcare utilization and costs. The case study introduces: a) main program features including rationale, goals, intervention design, and partnership development; b) illness burden and social barriers of the population contributing to care challenges and opportunities; and c) lessons learned with steps that have been taken to engage both patients and providers more actively in the care model. Urban health systems, including academic medical centers, must continue to innovate in care delivery through programs like J-CHiP to meet the needs of their patients and communities.

Going beyond Clinical Care to Reduce Health Care Spending

Background: Addressing both clinical and nonclinical determinants of health is essential for improving population health outcomes. In 2012, the Johns Hopkins Community Health Partnership (J-CHiP) implemented innovative population health management programs across acute and community environments. The community-based program involved multidisciplinary teams [ie, physicians, care managers (CM), health behavior specialists (HBS), community health workers, neighborhood navigators] and collaboration with community-based organizations to address social determinants. Objectives: To report the impact of a community-based program on cost and utilization from 2011 to 2016. Design: Difference-in-difference estimates were calculated for an inclusive cohort of J-CHiP participants and matched nonparticipants. The analysis was replicated for participants with a CM and/or HBS to estimate the differential impact with more intensive program services. Subjects: A total of 3268 high-risk Medicaid and Medicare beneficiaries (1634 total J-CHiP participants, 1365 with CM and 678 with HBS). Outcome Measures: Paid costs and counts of emergency department visits, admissions, and readmissions per member per year. Results: For Medicaid, costs were almost

Key Design Considerations When Calculating Cost Savings for Population Health Management Programs in an Observational Setting

1200 per member per year lower for participants as a whole,

Is bigger always better? The optimal size of a group practice.

2000 lower for those with an HBS, and

Going Beyond Clinical Care to Reduce Health Care Spending: Findings From the J-CHiP Community-based Population Health Management Program Evaluation

3000 lower for those with a CM; hospital admission and readmission rates were 9%–26% lower for those with a CM and/or HBS. For Medicare, costs were lower (−

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476), but utilization was similar or higher than nonparticipants. None of the observed Medicaid or Medicare differences were statistically significant. Conclusions: Although not statistically significant, the results indicate a promising innovation for Medicaid beneficiaries. For Medicare, the impact was negligible, indicating the need for further program modification.

The other side of healthcare expenditures

OBJECTIVE To illustrate the impact of key quasi-experimental design elements on cost savings measurement for population health management (PHM) programs. DATA SOURCES Population health management program records and Medicaid claims and enrollment data from December 2011 through March 2016. STUDY DESIGN The study uses a difference-in-difference design to compare changes in cost and utilization outcomes between program participants and propensity score-matched nonparticipants. Comparisons of measured savings are made based on (1) stable versus dynamic population enrollment and (2) all eligible versus enrolled-only participant definitions. Options for the operationalization of time are also discussed. DATA COLLECTION/EXTRACTION METHODS Individual-level Medicaid administrative and claims data and PHM program records are used to match study groups on baseline risk factors and assess changes in costs and utilization. PRINCIPAL FINDINGS Savings estimates are statistically similar but smaller in magnitude when eliminating variability based on duration of population enrollment and when evaluating program impact on the entire target population. Measurement in calendar time, when possible, simplifies interpretability. CONCLUSION Program evaluation design elements, including population stability and participant definitions, can influence the estimated magnitude of program savings for the payer and should be considered carefully. Time specifications can also affect interpretability and usefulness.