How to use and improve predictive models

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Congressional Budget Office: 27 million will lose coverage and premiums will increase by 50% if repeal ACA without replacement

In my last post, I noted that Congress was eager to repeal Obamacare, but lacked consensus on a replacement.  I noted that Obamacare was designed to cover the sick people and keep premiums affordable through the individual mandate and subsidies.  These two provisions of Obamacare can be reversed through legislative mechanisms that avoid filibusters.  But, removing those provisions, while leaving in place Obamacare’s prohibition of denial for pre-existing conditions creates an unstable insurance market that could lead to an increase in the number of uninsured people, and an increase in the premiums paid by those that continue to be insured.

Today, the Congressional Budget Office published a report offering some non-partisan quantitative estimates of those outcomes:

The clear implication of these projections is that pursuing the repeal of just the portions of Obamacare that can be repealed unilaterally, while leaving in place the popular prohibition of denial of coverage for people with pre-existing conditions would be a disaster.  Hopefully, these projections will help convince Congress to resist the urge to seek quick repeal to appease fervent anti-Obamacare constituents.  Hopefully, Congress will take a breath and take the time to build bi-partisan consensus on a more comprehensive and coherent design for our health care insurance system.

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Are high risk pools really a good replacement for Obamacare architecture?

Congress and the president-elect are enthusiastic about repealing Obamacare, but have not yet achieved any consensus about what to replace it with.  High risk pools figure prominently in various proposals, including Ryan’s “A Better Way” proposal.  But high risk pools are not a new idea.  Thirty five states had them in the years before Obamacare, so we have some experience to draw upon.  In general, they performed poorly, mostly because they were substantially underfunded, leading to high premiums and shameful waiting lists that withheld coverage for the sickest people – those that that needed coverage the most. The following explainer video was prepared last summer by the Kaiser Family Foundation, a health policy think tank.

Sounds Like A Good Idea? High-Risk Pools

High risk pools don’t reduce cost or risk. They just transfer it from private health plan premium payers to taxpayers — mostly state taxpayers. And, if the states fail to fund it properly (as has usually been the case), the wait lists associated with high risk pools creates a particularly cruel mechanism for keeping the most desperate citizens from the lifesaving care they need.

How did Romneycare and Obamacare Avoid the Need for High Risk Pools?

High risk pools consisted of the sickest people in the population. Since sick people incur health care expenses that they can’t afford, the money has to come from somewhere.  It can come from healthier members of the same health plan, from state taxpayers, or from federal taxpayers.  If it is to come from healthier members of the plan, there must enough of such healthy members to share the cost.  The healthy people can’t just wait until they are sick to buy insurance.  If too many healthy people opt out, the premiums for the people in the plan will be too high.  An insurance “death spiral” occurs when high premiums causes some of those healthy members to drop coverage, forcing premiums to go even higher for the remaining healthy members, ultimately leading to the failure of the plan.

So, to achieve coverage for sick people and affordability for all, the health insurance system must be designed to ensure that almost all the healthy people sign up for insurance, and that the healthy people don’t try to wait until they are sick to buy health insurance.   Romneycare and Obamacare attempted to accomplish this through two mechanisms:

  1. A subsidy for premiums for poor people to make them more affordable, and
  2. A “mandate” requiring that everyone have health insurance or pay a penalty.

However, as a political compromise to those that hated the idea of a mandate, the penalties were made quite small, making them only partially effective in getting enough healthy people to join the plan — ultimately causing the premium increases that people point to as evidence that Obamacare is “a disaster.”

Other than high risk pools, what is being proposed as an alternative to Obamacare?

I’ve seen nothing to suggest that there is any new innovation in health care finance that has been proposed as a superior solution.  So, what we’re likely to see is a return to health insurance designs that were used before Romneycare and Obamacare.  These mostly consist of the following:

  1. Reducing taxpayer expense by:
    • Kicking many poor people back out of government funded insurance plans (reversing federal subsidization of Medicaid expansion)
    • Reduce insurance benefits by covering fewer services and shifting more cost to patients for both government funded and private plans (reversing mandatory minimum benefits)
    • Allowing government funded insurance plans to negotiate with drug companies to demand volume discounts (against the wishes of the strong pharma lobby)
    • Increasing competition by reducing state-level insurance regulatory control to allow and facilitate building insurance plans that cut across state lines (against the states’ rights philosophy)
  2. Avoiding the insurance death spiral by:
    • Allowing insurance plans, once again, to reject sick people applying for private health insurance (reinstating pre-existing condition exclusions) and/or
    • High Risk Pools.

However, the president-elect and some members of Congress have claimed to be against some or all of these alternatives.  Except the last one — creating high risk pools. So, I think we’ll be hearing a lot more about that concept over the next few months.  Then, as people learn that high risk pools don’t do any magic and that they have a poor track record, I fear that framers of the “replacement” health insurance system will begin to acknowledge that replacement really means returning back to the other mechanisms listed above.

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Three ways to keep it simple — one of which is bad

“Keep it simple, stupid.”   The “K.I.S.S.” principle.  Generally a good idea, but not always.

Types of Simplification

Consider three types of simplification:

  1. Leaning.  This is about getting rid of waste. When simplifying a design, leaning involves getting rid of unnecessary features.  When simplifying communications, leaning involves getting rid of information that is duplicative, unimportant or just decorative.  Edward Tufte, one of my heroes, is a statistician, artist and graphical designer and zen master of simplicity. He famously rails against “chart junk” and advocates for maximizing the “data – ink ratio.”
  2. Summarizing.  This is about dropping one or more layers of detail.  It is accomplished by grouping smaller details into categories or themes and dropping the details from the communication.  Summarization makes the information “blurry” but still tells the truth.  Summarization satisfies some readers.  To others, it serves as an introduction and and invitation to dive deeper.
  3. Glossing.  This requires making the information conform to a desired level of simplicity, even if it means fibbing. For example, a system may have three components that interact with one another.  Describing the interactions may be tedious to explain.  The interactions may require additional arrows on a diagram.  Glossing it involves escaping this annoying complexity by denying it.   Many companies create diagrams describing the components that make up their product or solution.  As described in Ian Gorton’s book on software architecture, such marketing diagrams are colloquially called “marketecture” diagrams.  Designers of such diagrams often take great liberties with their depiction of the solution, portraying it as being made up of components that conveniently correspond to the sources of value to the prospective customer, even when the actual technology components are organized in an entirely different way.  Glossing it can sometimes be helpful to communicate some deeper truth, almost like a metaphor or parable.  But, often times, glossing involves intentionally obfuscating the truth, making the solution appear to be better or simpler than it really is.

Einstein Simplification

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First take on new CMS Comprehensive Primary Care Plus model

CMS CPC IconThis morning, I read about the recently announced next generation version of the CMS Comprehensive Primary Care model, which will require multi-payer participation and will involve up to 5K practices in 20 regions.

Sounds interesting.  I need to study it in more detail.  But based on my initial assessment:
  • I agree with the idea of pursuing payment and delivery system changes on a multi-payer basis to make it more compelling to providers.
  • I also agree with the idea of prepaying some E&M and then paying reduced FFS for E&M to cover only marginal cost of E&M office visits to make providers incentive-neutral on encounter modes.
  • But I disagree with move away from shared savings and implicit abandonment of the idea of non-governmental primary care-based organized systems of care pursuing care process innovation in favor of CMS taking over responsibility for defining a nationally-standardized multi-payer “care delivery model” and injecting it into individual primary care practices using a CMS-developed  “learning system.”
  • I also disagree with the Track 2 idea of partnering with “CMS-convened” IT vendors and contractual commitment to specific IT capabilities.  That approach basically takes MU, which was a huge distraction from real improvement, to even more obnoxious levels of micro-management.
Overall, I share the Fed’s frustration with the limited impact of previous efforts to transform primary care payment and delivery models, but I think the solution should be to define incentives which are more timely, coherent and consequential, enabled by more meaningful transparency requirements, clearer care relationships and some empowerment of primary care delivery organizations to define their own referral networks.
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Criticism of ProPublica’s Surgical Scorecard fails to consider the possibility of real, useful analytics.

From https://projects.propublica.org/surgeons/

Last week, ProPublica published a scorecard of surgical death and complication rates of more than 17,000 surgeons  for 8 elective procedures using Medicare data.  As with prior releases of health care performance metrics, the response against such “transparency” was swift and bitter.  Among those many responses is a thoughtful blog post entitled “After Transparency: Morbidity Hunter MD joins Cherry Picker MD” by Saurabh Jha, MD in The Health Care Blog.  Definitely worth your time to read.

But, although it is a clever bit of commentary, it implicitly presents a false choice between using data and not using data.

In my opinion, the decision should be conceptualized as:
  • Option 1: Not using data (and relying instead on subjective assessment or chance)
  • Option 2: Using reported metrics, interpreted by people who lack the talent and training to understand the limitations of the metrics and the methods that can address some of those limitations, and
  • Option 3: Using data, interpreted through analysis, conducted by and interpreted with the aid of people with such analytic talent and training.
By talent and training, I don’t mean technology mavens.  Keep your business intelligence professionals, data miners, “big data” experts, and most that claim the fashionable title of “data scientist.” I mean people that have training in epidemiology, biostatistics, health economics and other social science disciplines, and that have sufficient knowledge of health care.  People that can conceptualize theories of cause and effect. People that understand bias and variation.  People that can tell an interesting and actionable story supported by data, rather than just generate a “dashboard” or “score card.”  And, they must be people who have integrity and who are free of conflicts of interest that could prevent them from telling stories that are true.

Before anyone writes off option #3 as idealistic and infeasible, we should at least take the time to think through how we might make it work.

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How government surveillance of internet data relates to health care privacy and big data

Sound of Music ImageThis week, I accompanied my daughter and her elementary school classmates on a field trip to see the musical “The Sound of Music.”  To my daughter, it was a story about good vs. bad parenting.  But the context is 1930’s Austria, just as the Nazi regime is taking over.  The story illustrates how the battle for control, at least initially, takes place among business colleagues, neighbors, friends and even among family members.  And, it reminds us that, no matter how secure we seem to be in our personal lives and no matter how stable our society seems to be, our fortunes can quickly change.  We live in beautiful mountains, and those mountains have cliffs.

When I got home from the musical, I read the news reports regarding fresh evidence that the federal government may be engaged in electronic surveillance of the phone and internet communications of millions of people.  The new reports sparked a resurgence of the longstanding debate about whether such surveillance is a good thing because it might detect terrorist plots in time to disrupt them, or a bad thing, because it infringes our privacy rights and erodes the foundations of our liberty.  That’s a great debate for us to have.  That debate is oddly refreshing because it does not fall cleanly along  party lines.

Tyranny vs Anarchy ImageIn my opinion, it is a balancing act.  As amateur mountaineers, we hike along a treacherous ridgeline, with cliffs on both sides and slippery rocks underfoot.  On one side is the cliff of anarchy, where lawless invaders, terrorists and criminal gangs roam freely, pillaging our villages and murdering our children.  On the other side is the cliff of tyranny, where the checks and balances in our government break down, leaders get too powerful, levy heavy taxes, imprison or kill dissenters, and generally tell everyone what to do.  As I’ve noted before, most important things involve balancing between undesirable extremes. We must be vigilant to avoid falling over either side.

However, it is useful to note that the risk is not symmetrical.  The steepness of the cliff on the side of anarchy makes it look more frightening.  But the loose gravel on the side of tyranny makes that the more slippery slope.  Over the course of history, its seems as if oppressive leadership has been a far more common state than lawlessness.  So, my advice is to pay a little extra attention to avoiding missteps that erode checks, balances or rights.

How does this relate to health care?

Two ways come to mind.

First, our healthy debate about the privacy and accessibility of health care data is analogous.  One the one side, we want to defend the right of patients to control who has access to their own confidential medical records and for which purposes they are used.  On the other side, we want everyone who cares for us to have access to the information they need to enable them to make good decisions about our care, without missing any needed services or subjecting us to the risks of duplicative services.  Furthermore, our ability to assure the safety and effectiveness of health care processes, to hold health care providers accountable, and to learn what works and what doesn’t work requires access to data for populations of patients. We can error in either direction.  But, as with the ridgeline hikers, the dangers are not symmetrical.  In my experience, there are far more people harmed by medical errors caused by lack of access to information and by ineffective care processes than are harmed by inappropriate disclosures of their confidential health information.  So, we need to worry in both directions, but pay a little extra attention to avoiding missteps that erode our clinical decision support and our improvement efforts.

Second, our discussion of “big data” is analogous.  In both terrorist surveillance and health care, there is widespread faith in the value of large quantities of data, without regard to the quality and completeness of that data.  In an opinion piece published on June 7, 2013 on the CNN web site, Shane Harris, the author ofThe Watchers: The Rise of America’s Surveillance State,” challenges the evidence that surveillance data mining reduces terrorist events and saves lives. He asserts:

“To date, there have been practically no examples of a terrorist plot being pre-emptively thwarted by data mining these huge electronic caches. (Rep. Mike Rogers, chairman of the House Intelligence Committee, has said that the metadatabase has helped thwart a terrorist attack “in the last few years,” but the details have not been disclosed.)

When I was writing my book, “The Watchers,” about the rise of these big surveillance systems, I met analyst after analyst who said that data mining tends to produce big, unwieldy masses of potential bad actors and threats, but rarely does it produce a solid lead on a terrorist plot.

Those leads tend to come from more pedestrian investigative techniques, such as interviews and interrogations of detainees, or follow-ups on lists of phone numbers or e-mail addresses found in terrorists’ laptops. That shoe-leather detective work is how the United States has tracked down so many terrorists. In fact, it’s exactly how we found Osama bin Laden.”

This quote reminded me of our debates about “big data.”  As I’ve noted before, vendors of big data technologies sometimes over-sell.  They assert that the technology can overcome inadequacies in the structure, quality and completeness of source data.  They imply that the value of data is primarily a function of the size of the database.  Big data sources and technologies are undeniably valuable for some purposes, and will be an important part of our future in health care analytics.  But, as with terrorist surveillance, the real value tends to come from more pedestrian “shoe-leather” investigative techniques.

  • Proactively collecting the data needed to definitively answer an important question.
  • Hiring and developing people with advanced training in analytic methods, such as epidemiology, biostatistics, actuary sciences, and health economics.
  • Following leads to get to the bottom of something to produce information that is actionable, rather than merely suggestive.
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In the dust-up about “rebooting” the EHR meaningful use incentive program, “the Emperor has no clothes” has been the most interesting response.

Cover of Reboot Meaningful Use ReportLast month, six Republican senators released a document entitled “Reboot: Reexamining the strategies needed to successfully adopt health IT.” The report asserts that the original goal of the $35 billion EHR meaningful use incentive program was to achieve “interoperability,” creating a “secure network in which hospitals and providers can share patient data nationwide.”  The report expresses concerns that the meaningful use incentives and federal HIT policy in general are not achieving this interoperability goal and are instead increasing costs, leading to waste and abuse, threatening patient privacy, and leading to unsustainable IT infrastructure.

Since then, a number of parties have offered written responses, including the American Hospital Association, the Texas Medical Association, a consortium of consumer groups,  a group of EMR vendors and the “Healthcare Innovation Council.”  Both the senators’ document and virtually all of the responses agree with the premise that the health care system needs to be improved, and that improvements to health information technology are a necessary component of any effort to improve the health care system.  Almost all parties also agree that the $18.5 billion spent so far on stimulating EMR roll-out has not yet led to any great improvement in the health care system.  But, different parties express very different views about whether the incentive program as currently designed will eventually lead to such improvements.  And, among those arguing for “rebooting,” there are diverse opinions about what a rebooted program should look like.

On one level, the senators’ report fits into the frustratingly conventional narrative of political polarization, with senators from one pole arguing that the administration from the other pole is doing a bad job.  On another level, it fits into the deeper philosophical differences of opinion regarding the role of government spending and regulation vs. private enterprise in the health care system.  On a third level, the report represents the special interest views of one set of constituents, health care providers, who like receiving government funded incentives, but would prefer the bar to be lowered to earn those rewards.

Likewise, the responses defending the meaningful use program can be viewed as defending the administration’s record, promoting public involvement in health care, and representing the views of another set of constituents, the health care IT vendors, who really like the tsunami of revenue they are receiving as a result of HITECH and who fear that “rebooting” might end up more like “unplugging.”

The most interesting response

Logo for Healthcare Innovation CouncilA group called the Healthcare Innovation Council released what I consider to be the most interesting of the responses to the senators’ “reboot” document.  This Council was assembled by Anthelio Health, a health care IT outsourcing  company and consultancy that is not among the EMR vendor insiders that are reaping the greatest rewards from HITECH.  The Council includes a few leaders of health care provider organizations and leaders from other health IT and analytics companies not including any major EMR vendors.  Their report is entitled “Let’s Admit the Emperor has No Clothes: It’s Time to Redesign EHRs to Improve Patient Care.” They assert that EHRs have not led to the envisioned improvement in the health care system, and offer their diagnoses:

EHR design issues

    • “EHRs, to date, have been fundamentally designed to create electronic versions of paper medical records.”
    • “EHRs focus on data collection mostly for regulatory compliance and financial reporting, not to assist physicians, nurses and other clinicians in providing higher quality more efficient patient care. “

EHR implementation issues

    •  “EHR implementations are often led as IT projects by teams that do not obtain robust, meaningful, future-focused input/involvement from nurses, physicians, pharmacy and other clinicians who provide patient care. The end result typically is that EHR implementations don’t make life better for EITHER the clinician or the patient.”
    • “CMS’ and healthcare providers’ focus has been to ‘just get EHRs up and running‘ in a way that meets CMS’ meaningful use requirements so that they can get meaningful use dollars, without regard to how that affects patient care.”

I see the problem the same way.  But, the tricky part is the remedy.

The Healthcare Innovation Council’s paper first advocates for increased involvement by clinicians (with an emphasis on nurses) in the redesign of EHR technology.  On the surface, this is not really a controversial point.  The Council’s paper reverently referenced Steve Jobs twice in the paper as an innovator and simplifier.  But, it is interesting to note that Jobs was famously against too much end user involvement in the design process, arguing that users don’t have an easy time re-conceptualizing things.  People wouldn’t have asked for an iPod, an iPhone, or an iPad because they had never experienced them before and had established mental models of how to buy music, navigate, take movies, read books, etc.  The problem is on display within the Council’s document.  They write:

  • “EHRs are not designed to reflect or facilitate the way in which providers deliver patient care, and thus disrupt, rather than enhance, patient care”
  • “Improved focus on EHR design and implementation that starts by mirroring the way care is actually delivered by nurses, doctors and other clinicians.”

They seem to be asking for EMRs that “repave the cow paths,” a problem I’ve discussed in a prior post.  But, the Council at least seems aware of the difference between status quo and real disruptive improvement:

  • “This basic design then would move to new, information enhanced processes that not only help clinicians do their jobs easier, but measurably improve patient care safety and quality.”
  • “Rethinking, redesigning and re-engineering nurse, physician and clinician workflows to take full advantage of the capabilities of the new (and evolving) EHR tools to result in improved healthcare processes and care experiences.”

In addition to advocating for clinician-led EHR redesign, the Council’s remedy also includes having the federal government require providers to demonstrate “actual patient care improvement and better patient care process” to earn the incentives.  That’s a lovely thought, but imagine how many pages of regulation it would take for the federal government to define specific care processes that it considered to be “better” and methods to document that such care process changes were connected to the EHR technology.  Beware of what you ask for.

The last line of the Council’s paper is, perhaps, the most interesting.  The authors agree with the senators that it is time to “reboot” the meaningful use incentive program before all the money is spent.  Then, almost as a throw-away line, they add:

  • “Unless that is done, then we urge Congress to halt CMS’ “meaningful use” EHR program and spend the remainder of the “meaningful use” funds on providing financial incentives for hospitals and other providers that demonstrate “meaningful improvements in patient care” through whatever means they choose, and leave it to the healthcare providers, not our federal government, to choose the most effective means to improve patient care.”

Financial incentives for improvements in patients care is what value-based reimbursement is all about.  The Healthcare Innovation Council is basically saying that if you want effective, real improvement, rather than just superficial “compliance,” you need to pay for value.  Of course, the nation is transitioning to value-based reimbursement.  But that process is going slowly and the percentages of reimbursement that is value-driven has tended to be small.  As I’ve argued before, incentives tied to compliance is the opposite of real improvement, no matter how hard you try to make compliance meaningful.  If so, maybe we really need to consider re-allocating the remaining meaningful use funds to speed up the transition to value-based reimbursement, rather than just rebooting meaningful use.

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Physician-led ACOs now outnumber Hospital-based ACOs: Why this makes sense, and where our terminology breaks down.

At a recent meeting of the American College of Physicians covered in MedPage Today, Neil Kirschner, PhD reported on the growth of ACOs. Dr. Kirschner is the ACP’s senior associate of regulatory and insurer affairs. He reported that in March, 2012, there were only 136 ACOs  that had ACO-style gain-sharing contracts with Medicare, a commercial payer or both. Those ACOs included 91 “hospital-based ACOs” and 45 that were described as “physician-led ACOs.” In the last year, the number of ACOs has almost tripled from 136 to 391.  And, significantly, the 202 physician-led ACOs now outnumbers the 189 hospital-based ACOs.

ACOs by doctor vs hospital sponsorship 2012-2013

Why are physician-led ACOs growing faster?

The rapid growth of physician-led ACOs makes sense because ACO-style gain-sharing reimbursement arrangements are more favorable to physician organizations than hospitals. When a hospital-based health system enters into an ACO contract, it basically says “if you succeed in reducing the total cost of care (primarily by reducing your own hospital revenue), we’ll give you back a portion of your lost revenue.” That’s reminiscent of the old business joke “we lose money on each unit sold, but we’ll make up for it in volume.” But, from the point of view of a physician organization, particularly a physician organization that emphasizes primary care, the ACO contract basically says “if you do more primary care work to avoid the need for hospitalizations and emergency department visits, we’ll pay you for that extra work and we’ll give you a portion of the money we no longer have to pay to the hospitals.”

So, why would hospital-based organizations ever enter into an ACO-style gain-sharing agreement?  Two main reasons.

  • First, as a defensive measure. By forming an ACO in which they are involved, they can avoid or delay the formation of a physician-led ACO. It is better to be “doing” than to have it done to you.
  • Second, as a way to prepare for a potential future state where providers are bearing far more risk, such as in capitated reimbursement arrangements. It takes a very long time to develop effective population management capabilities, including establishing effective governance, building trust, deploying the right health information technologies and analytic systems, and, most importantly, recruiting and developing human resources that can effectively use data and improve care processes.

Ambiguous ACO Terminology

Finally, a note about the use of the term “ACO” and ACO growth statistics.

Many people get confused about the definition of ACO.   Some argue that an ACO is, by definition a specific type of Medicare reimbursement arrangement, the Medicare Shared Savings Program (MSSP), created by the Affordable Care Act (ACA).  But, I don’t agree that the term “ACO” defines a type of contract, and that the term ACO only refers to Medicare.  The “O” is for organization. On its face, the term refers to a type of organization, not to a type of contract.  When people generate statistics about ACOs, they should be counting organizations, not gain-sharing contracts.

I consider a provider organization to be an ACO if:

  1. It includes primary care physicians, and
  2. It has or plans to enter into at least one contractual arrangement where the provider organization takes responsibility for an attributed population of patients, and bears at least some risk for quality and economic performance

In common use, people are most likely to refer to a provider organization as an ACO if at least one such contractual arrangement includes a fee for service component with some risk sharing that includes at least some up-side opportunity to share in savings. The Medicare MSSP and Pioneer ACO contractual arrangements are just prominent examples of such contracts, not limiting to the definition of ACO. Because of that fee-for-service connotation, people don’t tend to describe a staff-model HMO as an ACO, even though they meet the definition I proposed above.

Furthermore, when categorizing ACOs, it is important that the categories are mutually exclusive.  The term “physician-led” seems to refer to an attribute of the governance of the ACO, such as whether the person serving as the CEO is a physician or whether the majority of the shares or votes on the board of directors are controlled by physicians or by people that are employed by physician organizations.  The term “hospital-based” seems to refer to whether the provider organizations that own the ACO include at least one hospital or hospital-based health system.  An ACO can include a hospital as a co-owner and still be “physician-led.”  Therefore, there is inherent ambiguity in the statistics comparing the number of physician-led to hospital-based ACOs.

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Beautiful video from Cleveland Clinic advocating empathy

We focus on optimizing care processes, analyzing data, implementing technology, and the other technical and scientific aspects of our work to improve health care.  But, this video created by the Cleveland Clinic is a touching reminder of the human element, advocating for empathy in our work.

http://www.youtube.com/watch?v=cDDWvj_q-o8&feature=youtu.be

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