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Anna-Lesa Calvert at TEDxBuffalo 2014

Anna-Lesa Calvert at TEDxBuffalo 2014

Anna-Lesa Calvert at TEDxBuffalo 2014

Anna-Lesa Calvert gave her first TED talk at TEDxBuffalo 2014 to a packed house on Tuesday, October 14. Since 2012, Buffalo Soccer Club (BSC) has developed and grown their Soccer for Success program in partnership with the US Soccer Foundation, United Way, and Independent Health Foundation. I just learned they’re now serving 700 kids (and their families) with a 24-week program at 20 sites around the lower-east and -west sides of the City of Buffalo. 84% of their players show real improvements or maintenance, season over season, on aerobic capacity, BMI percentile, and waist circumference. That’s exciting!

How does BSC encourage healthy lifestyles? Not by stopping play to hear lectures or watch film strips. They actually work healthy thinking into the game. Remember “sharks vs. minnows?” Try playing “Good snacks vs. junk!” Anna-Lesa bets that your kids can surprise you when they get tagged by a “good snack”, naming healthy foods like kiwi to get out of the junk team. You’d be surprised at how good kids are at coming up with fresh ideas.

Even more exciting, BSC recruits 50-60 coaches per season, and keeps the player/coach ratio low. Coaches show up before practice and games, and stay after too. While picking up cones, every player has the chance to talk to a real adult outside their everyday circle of teachers and parents. Players open up about problems, and coaches embrace them. In fact, coaches even get training on how to be better mentors. Who would you open up to when times get tough? BSC coaches care!

Buffalo Healthcare Conference Promotes Communication and Patient Engagement

P2Collab LogoThe P2 Collaborative of Western New York held their 2014 Creating a Healthier Community Conference on October 9th in Buffalo, NY.  As a technologist who usually works from the outside-in, I really enjoyed the opportunity to get some front-line perspective from the community.  Here’s a breakdown of the presentations:

Ellen Goodman – Have you had the conversation?

Ellen Goodman, Co-Founder and Director of The Conversation Project gave a powerful keynote on the importance of clearly identifying our end of life wishes.  This is a topic that can be difficult to talk about, but it’s often the deciding factor in whether the death experience is a good one or a difficult one.  The idea is much broader than the “pull the plug” stories we tend to hear about. In fact, Goodman points out that there’s “rarely a plug to pull”.  The conversation is more about making decisions around risky and/or aggressive treatments that offer marginal benefits while posing a significant risk to our quality of life near the end. Everyone is different. Do you want to exhaust all options regardless of the risk, or do you want to make sure you’re comfortable and with family when your time comes? Either way, its important that you make your preferences known.

Goodman proposed that the “Longevity Revolution” is the next big social change.  She felt that if we “fixed healthcare and aging, but did nothing to fix the way people die; then we’ve failed”.  The solution? Talk about it!  Social change happens when people share their stories.

Goodman also noted that the topic is too often discussed from the standpoint of cost, and unsurprisingly, that turns people off.  I agree that talking about it from the cost perspective will be ineffective, but as a society we cannot ignore that aspect. We spend incredible amounts of money on end of life care and the results are not always good.  In fact, Forbes Contributor Michael Bell wrote a post on end of life medical spending and found evidence that the less money spent in the final year, the better the death experience is for the patient.

So we’re spending a ton of money, negatively impacting quality of life and placing tremendous stress on patients, their families and care-givers.  The evidence certainly suggests we should all consider having the conversation.

Lastly, I wanted to share this video.  Goodman presented it as an example of how we can do better. It’s only 4 1/2 minutes and it shows how a provider made a meaningful impact on a terminal patient with one simple question: “What would be a good day for you?

If you need help getting started, download the Conversation Starter Kit.

Neighborhoods to Nursing Homes | The Conversation Project at ECMC

The Conversation Project team from ECMC followed up Goodman’s keynote with a very personal take on how they facilitate this in practice everyday. They’re often helping families have this conversation in times of great crisis when emotions and stress-levels are high.  They shared touching stories from their personal and private lives that showed how important it is to approach the situation with compassion and a clear sense of purpose.  To me, the main point was that we need to change the dialogue and tone from one that tries to “get the forms filled out”, to one that tries to find out what’s important to the patient. We need to know what they truly want.  During the Q&A session, a commenter added that when dealing with proxies, the question should not be “what do you want us to do for your loved one”, but rather “what would your loved one want us to do for them”?

The team shared some important statistics too:

  • 90% of us believe its important to discuss end of life issues with our loved ones. Only 30% of us actually do.
  • 60% of us say that it’s extremely important that our family is not burdened by tough decisions about our care.
  • 70% of us wish to die at home yet 70% of us die in a Nursing Home or hospital.

The most often cited reason for not having the conversation was that we thought it was “too soon”.  The ECMC team counters that :”It’s never to soon, but often too late”.

Thomas Workman, Ph.D. | Toward Shared Decision Making as the Norm: What We All Can Do

Workman defined the goals of Shared Decision Making (SDM) as follows:

  • A patient fully understands the potential benefits and harms of each option.
  • A patient applies their personal preferences, life circumstances, and values when making a choice.
  • Both patient and provider reach a mutually satisfying decision in which both have confidence.

The entire healthcare industry is moving towards a more patient-centered model and practices like SDM will help solidify the patient as the owner of their care.  Its THEIR decision and its THEIR life.  Workman notes that SDM lowers anxiety and lower anxiety has a proven effect on outcomes.  This transition will require the same type of deep and personal connection between patients and their caregivers that were discussed in the earlier sessions.

Mindy Thompson Fullilove, M.D. & Lourdes Rodriguez, Ph.D. | Introduction to Urban Alchemy

This was by far my favorite presentation.  Fullilove and Rodriguez’s style fit the event perfectly, because this felt much more like a conversation than a presentation.  Maybe without even realizing it, they gave us a live example of how to do what we’ve been talking about all day: Make a connection and communicate clearly.

It didn’t hurt that the topic itself was so interesting.  The speakers believe that “A strong city will power a large region” and that “neighbors that help each other are the foundation for making us well”.  With those ideas as the basis, they showed us how the concepts of urban alchemy can be applied to reverse the collapse of our communities and put us on a path to restoration.  They walked us through the steps taken to create Giraffe Path - an urban trail that connects the Cloisters to Central Park through the escarpment parks of northern Manhattan. The project connected disparate communities and gave them a sense of oneness. It also gave people a reason to get outside and move. A good one-two punch for community restoration and health.

This talk definitely put Fullilove’s book on my reading list: Urban Alchemy: Restoring Joy in America’s Sorted-Out Cities.

Franchelle Hart | Open Buffalo: Building Community

The day wrapped up with Open Buffalo – an organization focused on strengthening community ties and giving the entire population a voice.  Some keys programs from their website:

  • Mobile Democracy Center – will engage at least 1,000 residents per year with voter registration, information about equity issues, and advocacy tools to increase individual engagement and action while overcoming geographic and cultural divides.
  • Emerging Leaders – will train over 100 residents per year to mobilize their communities around equity issues and to take on leadership roles in community, nonprofit, and government sectors.
  • Innovation Lab – will build Buffalo’s capacity to generate new ideas, do original research, draw more effectively on local and national best practices, share information more broadly, and draft new laws and policies.
  • Open Buffalo Arts Network – will mobilize arts groups to aid in mobile democracy and emerging leaders projects, to contribute creativity to issue-based work, and to change the stories Buffalo tells itself and the world.

In Summary

I’m glad to have attended the conference and I plan to be an annual attendee from this point on.  The speaker/topic line up was great.  It gave me things to think about as a professional, but more importantly as a father, husband and citizen.  The conference made it clear that communication is key to our success and gave us some tools to begin improving our methods today.  I come away knowing that while it is important to examine and understand the entire population, healthcare needs to be delivered to the individual.


Buffalo Contingent Heading to Toronto to Talk Healthcare Innovation

TorontoOn October 14th representatives from The Jacobs Institute, Kaleida Health and dig Buffalo are heading to Toronto to explain how we’re building a Health Innovation Ecosystem right here in Buffalo, NY.  The announcement and RSVP info can be found here.

For those of you who don’t know what’s happening in Buffalo, we’re on the comeback trail. A couple of highlights:

  • Hundreds of millions of dollars in private investment rebuilding downtown
  • The Buffalo Billion – a pledge from Gov. Andrew Cuomo to invest $1 Billion to expand the Buffalo Niagara economy
  • Buffalo Niagara Medical Campus – a consortium of the region’s premier health care, life sciences research, and medical education institutions, all located on 120 acres downtown.
  • Thriving Startup and Tech Scene – Checkout digBuffalo, Z80 Labs and VCAMP for startups and NextPlex or Meetup for countless professional groups.

Given everything that’s happening here in Buffalo, I’m really excited to see the beginnings of a collaborative relationship with our neighbors to the north.  In a recent post, healthcare entrepreneur Geoff Clapp suggests that Toronto might be the next great hub for Digital Health.  He cites three key factors for this:

  1. The MaRS Innovation Centre - an “Innovation Hub” with an interest in healthcare and startups. Notably, this is the site of the Buffalo panel discussion on October 14th.
  2. Education System – University of Toronto Medical School and Waterloo head up a solid education system.
  3. People – From MaRS to the local Health 2.0 chapter, Toronto has some top notch people leading the way.

Clapp also points out that many of the healthcare startups in Toronto are targeting the US Healthcare market.  Given our proximity, entrepreneurial culture and bustling healthcare market, Buffalo can serve as an ideal jumping off point for entry into the US market.  If you’re curious how that might work, attend the panel and talk to Niall Wallace of Infonaut - an Ontario-born health entrepreneur who’s company is embedded within the Buffalo ecosystem.

Given the similarity in our ongoing efforts, it makes a lot of sense for Buffalo and Toronto startups/entrepreneurs/innovators to come together.   I’m thrilled to see that happening.



SIDE NOTE: If you’re in the startup scene and not looking at healthcare, read Healthcare’s Trillion-Dollar Disruption by Dave Chase.  The  idea that “new patient-centered population health models will cause more than $1 trillion of value to rotate from the old models to the new and create more than a dozen new $10 billion high growth markets” demonstrates the opportunity. This fact is also evident when you look at the growth in venture funding for digital health startups over the past 3 years (see chart).  Finally, and most importantly, work in this market can substantially improve people’s lives. Get in there entrepreneurs…

01_Rock Health Q3 2014 Funding Figures

Adrian Roselli’s Upcoming Speaking Gigs

One of the things I enjoy about my job is having the opportunity to share my knowledge and experience (and get corrected). This year already started out well with my talk at HTML5 Developer Conference back in May. Happily I have five more speaking engagements coming up in the next couple months.

WordCamp Buffalo

On Saturday, September 13, I will have the pleasure of speaking at WordCamp Buffalo for its (and my) third year. Based on the speaker line-up there will be plenty of great topics, so I look forward to being an attendee as well. My talk this year will be about accessibility.

If you are new to WordCamp Buffalo, a quick overview:

WordCamp Buffalo is a one day conference held in Buffalo, NY focusing on WordPress. Our goal is to increase knowledge about WordPress for people who already are working with it, and show some benefits of using it for anyone who may be interested, but aren’t currently working with WordPress.

Tickets are available now, so you have plenty of time to prepare for heckling me. This year the event is being held at the new Science Hall on the Canisius College campus. A map is embedded below, and information on metro stops, hotels, and parking is available on the WordCamp Buffalo site.

Accessibility Camp Toronto

I am excited to say that I will be speaking at Accessibility Camp Toronto in late September. It probably goes without saying that I’ll be speaking on accessibility. Given Toronto’s proximity to my home town of Buffalo, and the fact that I used to wander up to Toronto about once a month, it will be nice to visit a city I’ve neglected for a couple years now.

Instead of re-stating what Accessibility Camp Toronto is all about, I am going to cheat and quote the site directly:

Focusing on users with different disabilities, sessions can cover digital accessibility topics from the web (technical to tactical), desktop software, mobile apps, eLearning, online gaming, open source innovations, and everything in between. Watch this brief video from the first Accessibility Camp Toronto to get a feel for what to expect during the day. Also, video recordings from the 2013 camp are available.

Regardless of your level of knowledge, this event is for you. It will be a great opportunity for members of the design/development, usability, accessibility, other IT and end-users with disabilities communities to interact and learn from each other. We recommend you browse the Frequently Asked Questions, especially if you have never attended a participant-driven BarCamp/unconference before.

Please support the event with a $5 suggested donation at the door. Your donation will help cover the costs for miscellaneous expenses – event materials, food, etc.

Please follow event updates on Twitter via @a11yto.

Make sure you register as it is my understanding that the event is three quarters full. If you don’t follow @a11yto for updates, at least check in on the #a11yto hashtag.

The nitty gritty: the event is held from 9:00am until 4:00pm on Saturday, September 27, 2014. It is being held at OCAD University, 100 McCaul Street, Toronto, ON M5T 1W1.

UX Singapore

By far the farthest-from-home of my speaking engagements to date, I’m thrilled to be speaking at UXSG (User Experience Singapore). Having attended its sister event, UX Hong Kong (UXHK), last year I can say that I am excited not just to speak but to hear from all the other great speakers who will be imparting wisdom, knowledge, and perhaps a few local dining suggestions.

For those not familiar with it, UXSG is a three day event intended to onnect UX professionals across disciplines and cultures. As one of the founders of (way back in 1998), this statement from the conference organizers resonates with me: It is a platform made for and by UX professionals to foster stronger professional collaborations and personal friendships. Given that I made some great connections as an attendee at UXHK, I don’t doubt I’ll have a similar experience here.

I will be giving a lightning talk on the third day of the conference, Friday, October 3, at 11:00am Singapore time. I’ll be updating my “Selfish Accessiblity” talk for the UX audience. The abstract of my talk is posted at the UXSG site.

I’ve been to Singapore once before, but only for a day. This time I am looking forward to spending a little more time there and, in particular, experiencing the venue for the event, the relatively new Star Performing Arts Centre.

National Association of Government Web Professionals

Much as I would like to say that I will be speaking at the National Association of Government Web Professionals (NAGW, I don’t know where the “P” went, perhaps it was originally “Webmasters?”) conference in September, I won’t be. I was, however, asked to do a separate webinar for members for one of the conference topics I submitted — an intro to responsive web design.

As far as I know you need to be a member of NAGW to be able to attend the webinar, so I can’t share a URL, let alone a Google Map. I can, however, point you to the slides from a similar talk I gave last September: Slides: Responsive Web Design Primer

While the federal government may have its own crack web team now (or so the reports claim), state and local governments don’t have that same team and can’t as easily share their expertise. It seems NAGW fills a gap by providing a forum for these web professionals to share and help one another, as noted in its own description:

NAGW is the National Association of Government Web Professionals, an organization of local and state government web professionals working together to share knowledge, best practices, innovative ideas, and other resources. We collaborate on technologies, and network with other web professionals to improve our capacity to provide value across the web to our communities.

If you are a member, the webinar is Tuesday, October 21 at 11am mountain time. I hope I am able to provide some value to its membership, and if not, maybe they can be amused by how deftly I don’t do webinars.

Learning Choices Network

In a break from the last speaking engagements listed above, which have all been about web technologies and best practices, I get to list an event that isn’t about the web at all. Sorta.

Learning Choices Network (LCN) is a local (to Buffalo) organization focusing on alternative education such as self-directed learning and life-long learning. To let the organization speak for itself, this is from its Facebook page:

LCN exists to create, facilitate, and promote alternative opportunities for authentic learning in the local community while connecting educators, community advocates, parents, and business people who are seeking workable solutions for educational choice.

As someone who has built a career around the web, but for whom the web had barely sprung into existence when I started, being self-taught was the only option I had. For a sense of timing, Mosaic was released while I was in college (with Netscape Navigator soon to follow), so there weren’t classes to take, let along many with experience to help me get started. As I developed skills and started to rely on mailing lists to refine them, I co-founded and started writing, trying to become the kind of teaching and training resource I never had. I have been following that approach ever since (I believe evidenced by this very blog).

I’ve followed the same learn-as-you-go model for when I co-founded my business, Algonquin Studios, 17 years ago as well as other companies we’ve spun off since then. Just as I formed to help provide a resource like I didn’t have when I started, we’ve been spinning up VCAMP, our own local incubator/accelerator to help provide a platform for other business that we didn’t have when we started.

At the LCN event I will speak about how I started down my self-directed learning path, identified (and sometimes discarded) mentors, and somehow managed to be a (so far) successful entrepreneur when both the technology and economy have flolloped up and down like a mattress from Sqornshellous Zeta (sorry, it really is the best word to use). If you’re lucky, I’ll even (probably incorrectly) speculate on the future of education and learning, something for which I am woefully unqualified.

The event will be held from November 8 through November 10, 2014. Tickets are available online. The event will be held at Buffalo History Museum.

Eliminating 500,000 Avoidable Hospitalizations: Let the Data be your Guide

In my last post, we discussed the importance of regional and state-wide collaboration within the NYS DSRIP initiative.  This time we’ll take a look at the overall goal of the project, give it some context and look at some ways we can use open data sets to focus our efforts as we begin this 5+ year journey.

The goal: NY and CMS aim to reduce avoidable hospital use by 25% state-wide over 5 years. According to the DSRIP FAQ:

“Avoidable hospital use encompasses not only avoidable hospital readmissions, but also inpatient admissions that could have been avoided if the patient had received proper preventative care services.”

The following 4 measures will be used to measure DSRIP’s success:

If you combine the state-wide aggregates from each of these data sets, we’re looking at about 2.2 million instances of potentially avoidable hospital use. Those are our targets.  To reduce that by 25%, we must eliminate over 550K admissions!   To put that in perspective, if you think of each admission as an individual person, that’s enough people to fill Ralph Wilson Stadium more than 7 times!

Ralph Wilson Stadium - 7

This is a monumental task.  I suggest that DSRIP teams utilize the open data sets made available by NY DOH and others to “short-circuit” their planning and quickly focus in on the most advantageous targets.

If we take another look at the source data sets, we can see that they’re not equally represented across the state. In fact, Potentially Preventable ER Visits make up 95% of the pool with over 2.1M of the 2.2M potential targets!

Potentially preventable hospital use across NYS in 2012.

Potentially preventable hospital use across NYS in 2012.

In other words, we can eliminate ALL of the PPR, PQI and PDI state-wide and still fail miserably unless also we take a huge bite out of those ER visits.

So let’s start with the 95%. Are there any areas that stand out? Any low hanging fruit?

Lets identify the region with the most PPV Events.  In 2012, that distinction went to Kings County with around 350K events.  On the flip side, they were “expected” to have about 87K more.  Even though they had the most events, they performed better than all but 5 counties on a per capita basis.  Kings county is doing pretty well… probably not the place to start.

Who’s performing the worst relative to their NYS expected rate?  Comparing the number of actual PPV events to the expected number, we can identify the “Excess PPV” events. Since these counties are performing worse than the NYS expectation, they represent good places to start digging for answers and potential savings. The 10 worst performers by rate represent a pool of more than 65K events to target for elimination:

Actual PPV Events - Expected PPV Events = Excess PPV Events

Missed expectations: Worst PPV performers based on difference in observed vs. expected rate in 2012. Excess PPV Events = Actual PPV Events – Expected PPV Events

We could also target counties performing worse than expected, but prioritize those generating the largest volume of Excess events regardless of their per capita rate  – this group yields nearly 125K viable targets.  It also bumps 2 of the NYC region counties to the top of the list, reminding us that downstate might represent the biggest opportunity to move the DSRIP needle.

Worst PPV Counties by volume

Opportunities for change: Worst PPV performers by volume. Excess PPV Events = Actual PPV Events – Expected PPV Events

The data helps us to quickly identify some targets for further evaluation. Now we can  start doing the real work: Why is the ER so heavily utilized in St. Lawrence, Albany and Schenectady?  What’s being done differently in Kings and how can it be applied in these trouble areas?  Why is Kings doing so much better than nearby New York and Bronx counties? What innovations can we bring in from outside of NY? Here’s a few ideas that sound interesting:

We won’t find all the answers in open data sets, but they can really help us to focus our efforts. Let’s identify the low-hanging fruit, common problems and best practices and focus our energy on the areas that are likely to give the best results.  $8 Billion sounds like a lot of cash, but its going to go quickly in a state-wide effort incorporating 6-8 Million patients. We need to work smart. The data can help us do that.

CSS Summit 2014 Slides: Making Your Site Printable

This post originally appeared on my blog on July 15.

CSS Summit

This afternoon I awkwardly stumbled through my talk for CSS Summit, Making Your Site Printable. I can tell you that speaking to a screen instead of to a room full of people is a whole different experience than I was expecting. Fortunately for you I do not have an audio/video recording. I do however, have all the slides.


Making Your Site Printable: CSS Summit 2014 from Adrian Roselli


Links to resources referenced in the slides (in the order they appear):

Ticket Giveaway

I’d like to note that thanks to the generosity of CSS Summit, I was provided with two tickets to today’s talks that I could give away as I saw fit. I opted to offer them to two deserving young women from the Buffalo chapter of Girl Develop It (neither heckled me):

The Twitters

Finally, one of the novel things about an online conference is that attendees seem to be more active on Twitter. I got feedback and questions, and even fielded a few sub-tweets (I happen to know the print styles aren’t glamorous, but most of the fundamentals aren’t). I’ve collected the tweets in a Storify, which I have embedded here:

Update: July 21, 2014

Based on the activity from these two tweets alone, I am really hopeful that web developers are starting to see that print styles have value and belong in a responsive workflow. Only time will tell. The tweets:

A Simple Step to Growing Your Business Relationships

Dangling Conversation #2, Scott LoftesnessThere are people out there who can help you grow your business – as customers or vendors – that you aren’t talking to because you are prejudging them based on flawed assumptions. Consider that young tech entrepreneur who doesn’t follow you on Twitter because he’s not using it for business or the executive who doesn’t reply to your email because he gets 10K of them a day and missed it. You assume that all young people are on Twitter. They aren’t. You assume that your email makes it to everyone’s attention. It doesn’t. Its human nature to react negatively toward people you’ve valued worthy of your time and who don’t seem to reciprocate. But the truth is, most everyone is just as busy as you are.

So here’s the advice. Try to talk to everyone and see if there is a fit. But make the effort to talk to people you’ve heard negative things about to see if those comments are justified. If you’ve heard something about someone from a lot of people you tend to assume its true. But what if only one of those people has actually interacted with the “negative” person and the others are sharing opinions in a game of telephone? There is plenty of time in business to be cynical about relationships. I’ve run into my fair share of genuinely negative people in the business world and occasionally the person who can only claim a win if someone else claims a loss. But by and large, most people I’ve encountered are looking for a win-win and a long-term partner. Don’t let what is possibly one person’s opinion from one meeting on one day derail a possibly great relationship.

Stop wasting time and energy reacting to people you haven’t even interacted with and stop chasing people who won’t interact with you because of their perceived “value”. After all, the guy in the Lexus you think is going to invest in your business might be over-leveraged, while his plumber with the stained knuckles just cleared 1M last year.

Update to Verizon Using Disabilities to Fight Net Neutrality

In June I discussed rumors that Verizon was arguing, behind closed doors, that net neutrality harms those with disabilities.

Perhaps in reaction to the Verizon rumors, or just because the cause makes sense, on July 18 five different organizations related to accessibility filed their own joint comments with the FCC. The organizations are: Telecommunications for the Deaf and Hard of Hearing, Inc. (TDI), the National Association of the Deaf (NAD), the Hearing Loss Association of America (HLAA), the Deaf and Hard of Hearing Consumer Advocacy Network (DHHCAN)), and the Rehabilitation Engineering Research Center on Telecommunications Access (RERC-TA) along with Professor Clayton Lewis. Together they filed a brief, which you may read online (and which I have copied locally as I suspect this URL will be allowed to rot by the FCC), outlining their support of net neutrality. An excerpt:

[We] seek to promote equal access for the 48 million Americans who are deaf, hard of hearing, late-deafened, deaf-blind, or deaf with mobility or cognitive disabilities to the informational, educational, cultural, and societal opportunities afforded by the telecommunications revolution.

The letter outlines six arguments in particular, with far more detail in its sixteen pages:

  1. Retaining and improving transparency rules will improve the ability of consumers who are deaf or hard of hearing to access the Internet on equal terms.
  2. A no-blocking rule would help ensure the availability of accessible telecommunications services for consumers who are deaf or hard of hearing.
  3. The Commission should bar paid prioritization while ensuring that Internet-based services and applications are accessible to consumers who are deaf or head of hearing.
  4. Title II reclassification would afford the Commission additional flexibility to ensure that broadband services are accessible, and the Commission should exclude accessibility-related Title II provisions from forbearance if it reclassifies.
  5. The Commission should ensure that the enterprise services and premise operator exceptions avoid facilitating illegal discrimination against people who are deaf or hard of hearing.
  6. The Commission should ensure that the use of data caps do not result in discrimination against people who are deaf or hard of hearing.

The same day, the American Association of People with Disabilities and the National Council on Independent Living also filed their own joint letter with the FCC (also available from a non-FCC URL). In addition to an open internet, the letter argues for an ombudsman:

Over the past few years, Congress shifted the focus of universal service from mere availability to adoption and utilization. […] This important review of Open Internet policy provides an opportunity to ensure that people with disabilities have full and open access to broadband communications and enjoy the important consumer protections mentioned in our comments. […] An Ombudsman Office Can Monitor and Report on Access Issues Associated with Consumers with Disabilities

Ars covered the latter filing in its Tuesday, July 22 post, “Deaf advocacy groups to Verizon: Don’t kill net neutrality on our behalf.”

Hopefully these two are among the comments that will work their way to the top of the pile of the 1.1 million of comments the FCC has received (good luck finding them on your own). And then hopefully they’ll be read, and understood, as the FCC weighs the information in making a decision on net neutrality.

Competition in DSRIP?

competitionraceLet’s talk about competition for a moment. As a result of its approach, the NYS Department of Health received fifty DSRIP design grant applications covering 11 regions in NYS. Although the state urges collaboration to reach the point where there’s just one Performing Provider System (PPS) per region, only five of eleven regions have just one PPS today. In fact, we have five PPSs in WNY. In NYC, there are twenty.

Clearly the state’s goal is not reality in the field, at least not this quickly. Many of the lead organizations have been bitter rivals historically. It’s unclear to me whether the state will award design grants in a way that forces team mergers, or whether they’ll allocate Medicaid patients proportionally and let PPSs compete within a region. While competition could be seen as breeding duplication of service (wasteful among not-for-profits), it’s easy to forget that this is a pay-for-performance incentive program.

Incentive for what? Both for taking on more programs, and for delivering effective strategies. On this second point, I think there’s a lot of room for competing PPSs within a region. DSRIP is an experiment that tracks outcome performance and the money spent on it. Even though there may be a wide variation in the size of competing PPSs in a region such as WNY, couldn’t a smaller PPS with an innovative and more effective program teach it to others? A rising tide lifts all boats.

We’re still missing competition from the patient’s perspective. I understand that NYS Department of Health expects to assign each Medicaid patient to a single PPS, reducing choice (if you don’t want to move to a different region). This also leaves a lot of questions open. What happens if you feel that the PPS failed you? Is there an appeal process to get a different provider? Will changing providers in the same PPS be enough to overcome the problem? How quickly can you get a different provider? What pressure makes sure your dissatisfaction gets included in metrics to the state, since PPSs self-report?

From the collaborating provider’s perspective, things could be just as difficult. Imagine you’re a provider located in a rural county in WNY. All five PPSs in your region are strongest in urban parts of Erie and Niagara Counties. Does that mean you’ll be participating in several PPSs so they can cover rural patients? How will you manage separate processes and systems for several Medicaid patient pools without losing money from the administrative burden?

I think these kinds of problems need to be worked out during the program design period between now and March, 2015.



DSRIP as Organizational Behavior: Top Down Part 2

emergencyredsmockContinuing my last post, I think the Delivery System Reform Incentive Payment (DSRIP) has a lot of teach anyone learning how to change an entire industry from the throne of the main payer. It’s happening right now, like an experiment in action, to reduce preventable hospital admissions by 25% over five years.  The same program from the Centers for Medicare and Medicaid Services (CMS) at the federal level, DSRIP, has been implemented in different ways by different states.

Lesson #6: Give participants many ways to accomplish an objective, and let them choose the ones that suit them.

Medicaid has the reputation among payers of offering break-even compensation at best, and CMS has reformulated it under DSRIP as a potential money-maker. How? CMS offered states a menu of programs they could take on.

Lesson #7: Setup projects to share the risk and incent behaviors that accomplish the change you envision.

Each program comes with a tradeoff. The revenue per patient per month in the program has a cap. There are a bunch of factors that affect the cap, influencing your choices and strategies in pursuit. But setting that aside for a moment, if it costs you more than the cap to take care of your population, you lose. Likewise, if it costs you less then you gain. CMS and the state Department of Health have chosen projects that they believe will lead to more efficient delivery of care, so that CMS and the State can ultimately target spending less while providers keep a larger share than they do today – a win for both sides. Going further, the state even setup a High Performance Fund worth up to 30% of DRSIP project value for closing the gap to goal to 20% or placing within the 90th percentile of all PPSs in the state.

Lesson #8: Pay for performance, and give time to get the process down initially followed by actual outcomes later.

Looking at those factors affecting the cap again, some cover outcomes: projected ones at the start and actual ones later. Also, the state expects participants to report on defined metrics at the start and real performance later.

Lesson #9: A project advisory committee can increase partner accountability and investment in the team.

Many of the safety net, behavioral health, and community health providers partnered with hospital systems have never collaborated before. Who will charter project committees, enforce compliance with reporting and metric gathering, oversee financial transactions? The state requires each PPS to establish a Project Advisory Committee made of representatives from each collaborating partner.

Lesson #10: Identify key resources for your program to succeed and make sure they’ll survive the transition.

Earlier, we mentioned Medicaid’s reputation as a low-reimbursement program. Some of the hospitals serving Medicaid patients may not survive the uncertain transition to payment for value. This risks losing some of the critical capacity to serve the population, which would likely cost more to replace than to bridge. To counter this, in parallel NYS is offering $20M in Interim Access Assurance Funds to four WNY hospitals.

Lesson #11: By tying all providers in the state together to avoid a penalty, you can encourage collaboration.

Under DSRIP, a lead PPS can do great but still not earn its full incentive. How? There are four statewide goals that must be satisfied, or all PPSs will suffer a proportional reduction in payments. The goals include statewide metrics, composite success of projects, growth in Medicaid spending kept to less than the trend, and overall adoption of reimbursement for value (not service). The state formalized a Learning Collaborative program to transparently share best practices, but I suspect this will only work in the absence of competition. This also gives the state a relief valve to re-negotiate the program or pull the plug if it fails to hit its big picture goals, regardless of how the blame gets dished out.