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It’s a healthcare axiom: asthma patients often
think they’re controlling the condition when
they’re not.
“In the physician’s ofce,
invariably they say they’re
ne. But when you say, how
many times are you waking
up at night with a cough, or
how many times you use
your quick reliever at night,
how many times do you miss
work, then you nd
objectively these patients are
poorly controlled,” said
Pankaj Patel, M.D., director
of medical quality of
management for Advocate
Physician Partners in
suburban Chicago.
Patients have low
expectations. They think,
“that’s how I have to live,”
Patel said. “We have to
educate people to realize,
you can have asthma and
be a world-class athlete.
You should feel great.”
Advocate Physician Partners, an afliate of
Advocate Health Care, the largest integrated
delivery system in northeast Illinois, has
developed a comprehensive asthma program
that has achieved real results. Across the
board, Advocate’s asthma patients have a
control rate of 88%, vs. 50% for the country
as a whole. The system estimates this has
saved almost an additional $13 million in
direct and indirect medical
costs above national averages
annually. This includes an
additional 58,436 days saved
from reduced absenteeism
and lost productivity.
For many years Advocate
has devoted intensive focus as
a system on a handful of
chronic diseases, including
diabetes and postpartum
depression. For asthma, it has
developed training programs
for clinicians, special tools for
physicians and patients, an
electronic patient registry, as
well as hired a new cohort of
care managers to work
with the most difcult
In 2008, an estimated
23.3 million American
were affected by asthma,
or one-twelfth of the population, and the rate
is rising. Direct medical costs from asthma are
$15.6 billion; indirect costs from lost
productivity come to $5.1 billion, for a total of
$20.7 billion.
October 5
September 14-16
30 August 2011
September 8
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the details of your event, or call
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Midwest Edition
Advocate Invests in Asthma Control
Chicago System is Gaining Ground on Outcomes
Continued on Next Page
Pankaj Patel, M.D.
Advocate Physician Partners
Payers & Providers
Page 2
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In Brief
Sanford Health
to Construct $360M
Hospital in Fargo, N.D.
Sanford Health will build a new 371-
room hospital in Fargo, N.D., costing
$360 million. Construction will begin
in 2013 and the 11-story facility
should be nished in 2016.
There will be 30 operating rooms,
40 emergency treatment rooms, 10
cardiac catheterization laboratories,
and 300 clinic exam rooms. The
hospital is expected to house a
medical staff of 200 physicians and
employ 2,700 persons.
It will have ve centers of
excellence: children’s health, women’s
health, heart care, and orthopedics-
sports medicine. A cancer center will
be located in downtown Fargo.
Kansas City Leaders
Voice Worries about
Regulatory Uncertainty
to Top HHS Official
Business leaders in Kansas City told an
Obama administration ofcial that
they are reluctant to invest or hire new
workers because of uncertainty about
federal regulations and policies.
Last week E.J. “Ned” Holland,
assistant secretary for administration at
the Department of Health and Human
Services, visited with about 30
representatives of local companies to
hear their views on how well the
government is functioning.
“The obvious stark disagreements in
Washington that lead to last-minute
solutions to things … there’s more of
that today than there’s been in the
past,” Holland told the Kansas City
Business Journal.
“I’m not sure how you solve that.
This country is strong because it has
different views, but if it produces a
Continued on Page 3
Asthma in Chicago (Continued from Page One)
The Chicago metropolitan area is an
epicenter of the rising toll of asthma. “Chicago
is known for many great things,” said Maureen
Damitz, chairperson of the Chicago Asthma
Consortium. “Unfortunately, we are also
known for the worst outcomes for asthma in
the country.” Prevalence rates in Chicago
resemble those elsewhere: almost one in four
African-Americans have asthma, while the rate
is one in nine among Caucasians.
What distinguishes Chicago are its
atrocious outcomes. “We have some of the
highest hospitalization rates and highest
morbidity and mortality rates due to asthma,”
Damitz said. “What is puzzling is we don’t
know what makes Chicago unique, and what’s
causing these disparities.”
Causes of asthma include air pollution, age
of the housing stock, chemical pollutants in
homes, insets, antigens, and other issues
around which there is still controversy.
Doctors can’t mitigate these causes, but they
can inuence how patients respond to them,
said Mark Shields, M.D., senior medical
director of Advocate Physician Partners.
“We have an asthma action plan, an
individualized prescription for patients telling
them what they should be doing based on
their symptom level. These tell them activities,
medications to be taken, triggers for asthma,
things that cause asthma attack and make it
worse -- smoking, exposure to second-hand
smoke, being near allergens that affect the
patient, cats or dogs, those kinds of things.”
The individual action plan goes through those
triggers and how to avoid them.
Some years ago a National Institutes of
Health study revealed that controller therapy
was underused and that many patients didn’t
know how to manage their condition. At the
time, only about 20% of patients with asthma
were considered candidates for controller
therapy, while 80% were considered mild
intermittent asthmatics.
“In fact it turns out it’s actually the
opposite,” Patel said. “The majority of patients
should be on the long-acting controller
Advocate decided it needed to engage
more directly with asthmatic patients. It built a
system-wide infrastructure to try to bend the
trendlines. The system leadership got behind
the effort with money to develop programs
and hire trained staff.
“The rst thing we did,” Patel recalled,
“was develop a registry” to cover the total
population of patients with asthma. At each
encounter, the database is updated to show
who is on controller therapy, who’s not, who
has gone to the emergency room, who has
received an updated action plan.
If a patient is brought to one of Advocate’s
10 area hospitals, he or she is seen by the
asthma coordinator, a new position created by
the system as part of the comprehensive
The small portion of high-risk patients who
are having trouble gaining control over their
exacerbations are linked with a care
coordinator, another new position.
“If the patient doesn’t adhere to what the
doctor wanted them to do, the care manager
spends a lot of time talking through what is
not working,” said Sharon Rudnick, the
Advocate vice president in charge of
outpatient care management. “What are the
barriers to your managing your asthma? What
are the triggers making you sick? Did you get
your medications lled? Do you understand
how to take them?”
These are the kinds of things that patients
say they understand, “but sometimes they
don’t really get it,” she added. The care
managers build a relationship of trust to help
them gain mastery over their illness.
Chicago’s issues are hardly unique, said
Mario Castro, M.D., who leads the
Controlling Asthma in St. Louis study, funded
by the Centers for Disease Control and
Prevention. “At Barnes Jewish Hospital, we
have identied as one of the contributing
factors in asthma morbidity leading to
hospitalizations is that patients don’t have a
good concept of their disease itself, the
importance of the medications and how to use
His study took a group of 100 persons who
had been admitted frequently to the hospital
and hired nurses to work with them. That led
to a 50% reduction in admissions, which
saved the hospital more than the cost of the 12
new asthma educators, because the patients
were mostly self-pay for whom the hospital
received little compensation. Barnes Jewish
saved $6,000 per enrolled patient, Castro said.
For all this new infrastructure and system-
wide coordination, can Advocate move the
dial on what ails Chicago?
“Unfortunately, Advocate is not always in
some of our hardest hit communities,” Damitz
said. Those tend to be on the South Side and
the West Side, where Advocate doesn’t have
hospitals or many clinics.
Still, she said, “I think what they are doing
is great. It’s not just access to care, it’s access
to quality care.”
Page 3
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In Brief
result where (business leaders) don’t
know how to invest their money
because they’re not sure what the
result is going to be, it turns out to be
The business executives asked him
to improve the regulatory environment
by eliminating rules that do more
harm than good, and by not stalling
for months while it deliberates on new
Holland was formerly a human
resources executive at Sprint, based in
Overland Park, Kan., and was active
in the region’s healthcare community.
Michigan Court
Reverses Legislature’s
Health Expense Bill
for State Employees
The Michigan Court of Appeals
overturned a bill by the state
legislature that required public
employees to pay 3% toward the
healthcare expenses of retirees.
The panel of three judges afrmed
a decision by the Michigan Court of
Claims, and said that state lawmakers
failed to respect the system of checks
and balances in the Michigan
The appeals court said the
legislature in 2010 was trying to make
up a budgetary gap. It couldn’t put
together a tw-thirds vote necessary to
void a 3% raise for state employees.
That raise had been authorized by the
Michigan Civil Service Commission.
As in other Midwestern states, the
legislature has been trying to nd
ways to curb spending on state
employee payrolls, often by reducing
health benets or by requiring state
workers to shoulder more of the
expense burden of their healthcare.
Plans to create a health information exchange
in Kansas are moving forward despite Gov.
Sam Brownback’s decision to return a $31.5
million early innovation grant to the federal
government. (Payers & Providers, Aug. 16
A rump coalition of roughly 60 patient
advocates, attorneys, and healthcare
representatives met in Topeka on Aug. 24 to
consider reviving the health exchange
concept. Insurance Commissioner Sandy
Praeger told them that 15 states have enacted
enabling legislation to create exchanges,
according to the Kansas Health Institute.
Residents of states that don’t develop an
exchange will have one provided for them by
the federal government.
The exchanges are intended to be internet
marketplaces where families or small
businesses may compare health insurance
plans for price and coverage, and also nd out
whether they qualify for tax advantages or
subsidies. Five of the seven states that won
innovator grants are moving forward with
them, Praeger said, including Wisconsin,
which also has a Republican governor and
insurance commissioner.
“We are still working with the grant,” said
Jim Guidry, in the Wisconsin Ofce of the
Commissioner of Insurance. “I have not been
told that we are planning to return the money.
My assumption is that we’ll move forward
with the work of implementing the exchange.”
Some leaders in Kansas, however, voiced
skepticism at the likelihood of the governor or
the House of Representatives would come
“I’m very pessimistic,” said former Attorney
General Bob Stephan. “I’m doubtful the
governor will change his mind.”
The state of Illinois stripped the professional
licenses from 26 physicians, nurses and
healthcare workers last week when a new law
barring certain kinds of offenders from
practicing went into effect. Among them were
11 healthcare workers who had been convicted
of sex crimes or violent crimes.
The legislation, signed by Gov. Pat Quinn in
July, requires the revocation of the professional
license of any healthcare worker who has been
convicted of a sexual offense or violent crime
against their patients. The healthcare workers
are not entitled to a hearing and may not be
licensed again as healthcare workers in the
“The state takes its responsibilities to protect
our residents seriously,” said Brent E. Adams,
Illinois secretary of nancial and professional
regulation.! “This new law establishes tough
outcomes that are intended to shield Illinois
patients from healthcare workers who have
been convicted of sex offenses and certain
violent crimes.”
On the list were 10 RNs, 14 physicians and
surgeons, and two pharmacists. Three of the
delisted nurses were women, each of them
convicted of sex crimes against minors. Eight of
the 26 had been convicted of possessing child
The law was passed after a Chicago Tribune
investigation discovered that many healthcare
professionals convicted of crimes against
patients were still practicing and had not been
disciplined by regulatory boards.
One doctor contacted by the Tribune said
he would ght revocation because he has
already been punished for his offense and has
been following restrictions placed on him by
the agency, such as keeping a female assistant
in the room when treating women.
Venkatesan Deenadayalu, M.D., 65, was
convicted of misdemeanor sexual abuse and
battery of a patient in 1999. His license was
suspended but he resumed practice in 2008.
Five other practitioners have led suit
challenging the agency’s interpretation of the
law. Several of the revocations were put on
hold by the courts. The lawsuits argue that the
state can’t take away the licenses of
practitioners who have already been punished
in the legal system.
Several legal experts said the challengers
might have a strong case. The practitioners are
being penalized for something that didn’t
qualify for that particular sanction at the time
the crime was committed, they noted.
Illinois Revokes Professional Licenses
New Law Penalizes Practitioners for Previous Crimes
New Momentum for Kan. Exchange
Group Convenes to Revive Insurance Concept
Payers & Providers Page 4
Accountable care organization (or ACO). You
need to go back 30 years to DRG (followed
quickly by PPO and HMO) to nd a three-letter
acronym that has ignited as much buzz. At
present only a handful of “trial” accountable
care organizations have emerged, yet we
already know three irrefutable truths.
The rst is that ACOs will elevate competition
to a level many communities have never seen.
That’s because as hospitals work to align
themselves with physicians, their competitors
are doing the same. More than ever, winners
and losers will emerge, necessitating hospitals
to be more aggressive, more strategic and more
open than ever before to taking calculated risk.
A second truth is that ACOs
are likely to spawn a new era of
cost shifting. This concept is not
new to healthcare; those who
could pay have always fronted the
burden for those who couldn’t.
But as hospitals become
accountable for the care of an
entire community, it will be even
more important to have a strategy
in place to attract favorability
insured consumers. That brings us
to the most important truth of all.
ACOs are about relationships.
Looking at the nation’s most
successful integrated healthcare
systems – Geisinger, Inova
Health, Kaiser – it is clear that for ACOs to
succeed, hospitals and physicians must align
their incentives and establish a relationship
built on trust – one where “win-win” becomes
more than a cliché.While many hospitals
already have a physician relationship
management program in place, few are
achieving signicant impact. That is because
instead of seeking opportunities for strategic
alignment and ongoing engagement, these
programs are often built around outdated
“meet-and-greet” activities or simply address
quick xes such as more convenient block
times in the operating room.
According to a survey by the American
College of Physician Executives, only 16
percent of ACPE members rated the relationship
between hospitals and PCPs as “doing well.”
That is a frightening and untenable statistic.
One of the most effective ways to bridge this
gap, according to the ACPE survey, is to
implement a formal physician relationship
management program.
When optimally planned and executed, such a
program can create three critically-important
Referral Alignment – By working with PCPs to
uncover barriers and help foster connections with
specialists, hospitals can facilitate a steadier ow
of patients. Referral alignment also helps identify
challenges physicians may be having with
accessing and delivering services at the hospital.
Strategic Alignment - While most hospitals have
a loyal group of admitting physicians, often the
majority are “splitting” referrals between several
hospitals. There are also likely physicians in the
community who have chosen not to join the
medical staff at all. Strategic alignment helps
educate physicians about the
benets of associating with the
hospital and invites them to be
part of the decision-making
process, which can translate into
increased personal and
professional satisfaction.
Economic Alignment - Like
hospitals, most physicians have
seen their income decrease as
reimbursement declines. Many
doctors are looking for new ways
to grow their income, such as
through joint ventures or adding
new services. Hospitals can help
identify gaps in services within
the community and, where
appropriate and allowable, partner with
physicians to ll those voids and foster market
share growth.
Today, more than ever, hospitals need to enact
a physician relationship management program
that identies potential growth markets, targets
physicians most likely to drive new referrals, and
addresses a physician’s core needs and
professional goals. Only through this data-driven
approach can hospitals and physicians achieve
the kind of competitive advantage needed to win
in the world of ACOs.
Op-ed submissions of up to 600 words are
welcomed. Please e-mail proposals to,
By Pearson Talbert
Getting Past The Initial Buzz On ACOs
Relationships Will Differentiate What Works And Fails
Pearson Talbert is the president of Aegis
Health Group, a hospital consulting firm in
Brentwood, Tenn.
Payers & Providers Page 5

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