health care

Five Questions With: Dr. David Keller

"Administrative work is something we all dislike, we prefer being in the room with the patient, but if you need to do it, you want it to be something that is going to help patients."
Posted 7/29/13

After two and half years as co-director of the R.I. Chronic Care Sustainability Initiative, Dr. David Keller, a pediatrician, is moving on. He will be working with the Colorado Children’s Hospital, which has a service area that extends from Oklahoma to Montana. Keller will also be serving as the vice chairman of clinical affairs and clinical transformation in the Department of Pediatrics at the University of Colorado School of Medicine.

Providence Business News sat down with Keller for an early morning conversation about where CSI-RI is, where it is headed, and the prospects for a new initiative focused on pediatric practices, known as CSI-Kids.

PBN: Why did you decide to leave?

KELLER: I am leaving because I’ve been offered a unique opportunity elsewhere. And it was a really hard decision, because I really like what I’m doing here. The Colorado Children’s Hospital is a free-standing children’s hospital; there aren’t many of them around. It has a service area that extends from Oklahoma to Montana.

They recognized that health reform is happening, and children’s hospitals don’t really know what the right thing to do in health care reform is. They weren’t part of the discussion, so they weren’t part of the solution, and they were not really part of the discussion. So they found themselves in a position of having to navigate that.

PBN: When former R.I. Health Commissioner Christopher F. Koller spoke at the R.I. Healthcare Reform Commission at the end of June, he said that the numbers from CSI-RI in terms of moving the needle on costs were not what he had hoped. Why is that?

KELLER: As we’ve all been finding over the past couple of years – and this is what is being found nationally – is that to transform a health care system is hard and it takes time.

What we’re seeing in CSI-RI is a tremendous transformation of the practice and the workplace. Primary care doctors, who, if you asked them five years ago, [would tell you that they] were miserable. Today, the ones working in this new model are happy, relatively speaking – as happy as doctors ever get. They enjoy the work environment, they are finding that they can take better care of their patients, and they are finding that the administrative work that the are asked to do has meaning, that it actually helps them to do patient care better.

Administrative work is something we all dislike, we prefer being in the room with the patient, but if you need to do it, you want it to be something that is going to help patients.

In terms of clinical outcomes, the ones that we were able to measure, we achieved tremendous gains in control of blood pressure, in management of diabetes, and in implementation of preventive services.

In terms of measuring finances, this is a challenge, because we’re trying to measure the financials based on all the payors. No one has ever done that before.

What we found was that the rates of hospital utilization and emergency room utilization are decreasing, but not decreasing as fast as we’d hoped. They are going down, but they’re going down slowly, and they’re oscillating. It’s not a smooth curve.

Initiatives around the country are seeing the same thing – it’s a slow, gradual downward trend, but it’s not game-changing.

PBN: In its shared-savings contracts, Coastal Medical has found that 20 percent of the costs are from inpatient hospital services, and 80 percent are from other sources, with about 20 percent of those costs coming from drugs. Have you found a similar breakdown in your data?

KELLER: What we’ve been able to measure so far is emergency room utilization and hospital readmissions. Those are the easy things to measure, the low-hanging fruit. What we should really be measuring is the total cost of care. That’s a tricky thing, because the question of cost is always, cost for whom? The patient? The hospitals? The insurance companies?

PBN: As the CSI-RI initiative continues to expand, having just added 20 new practices and covering about 200,000 Rhode Islanders, have will that additional market share change the potential influence? Will you consider becoming part of an innovative network health insurance plan on the new HealthSourceRI market, joining with hospitals and insurers?

KELLER: So far, we’ve only had about 10 percent of the market. So to influence societal trends with such a small market share is really hard. With 20 percent of the market, we’re getting there.

One of the things we heard from Christy Ferguson, [executive director of HealthSourceRI, is that she would like to offer limited network products that offer high value care. We weren’t ready yet, because we didn’t have enough practices or options. In the future, it may be possible. It won’t be CSI, per se, meaning that we’re not trying to set ourselves up as an ACO. I want to be clear about that, we’re not trying to form a rival corporation or anything like that. What we’re hoping is that we will have developed a collaborative of practices that function at a high level that can be formed into a functioning network. It would give a plan the ability to offer a wide range of options to patients while still giving them a high-quality, high-value service.

PBN: How does the new initiative, called CSI-Kids, focused on pediatric practices, fit into the equation?

KELLER: One of the challenges in implementing health care reform is that you have to answer the question that’s being asked. In 2009, in Washington, D.C., the question was: how do we bend the medical cost curve for the next six months? And it’s very difficult to demonstrate rapid changes in cost and outcomes from pediatric initiatives.

The focus for the last five years has really been on adult care.

I have been pleased that Koller and Secretary [Steven] Costantino said, yes, we need a kids’ initiative, let’s design one.

It will be introduced when it’s designed. We have a meeting this afternoon to keep hacking at the design. The challenge is two-fold. At the heart of CSI is the goal of changing the nature of the practice and measure the outcomes. With adults, we’re doing that with chronic disease, with the goal to catch the disease early enough and treat it.

The goal of health care for children is to maximize the potential, and what we are lacking in pediatrics are [agreement on] the right measures. A lot of the measures to ensure that a kid is maximizing his or her potential are not in the health care arena, like: did they graduate from high school?

Child health is also challenging because the interventions are multi-system, an intervention may involve health, education and housing. The challenge within government would be for these three part of government that don’t talk to each other to start talking to each other.

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