In This Issue


 

In Focus: Protecting Patients with Compromised Kidney Function During the Pandemic and Beyond

After catastrophic events like hurricanes or wildfires, there are protocols for ensuring people with end-stage renal disease (ESRD) whose lives depend on receiving regular dialysis can still get treatment, often by temporarily moving them to different cities. But our current situation is different; not only is the coronavirus pandemic an ongoing, evolving threat, it puts people with ESRD — who are often elderly, sick, and /or immunocompromised — at great risk as they congregate in dialysis centers.  

What’s more, emerging data suggest some 20 percent to 40 percent of people being treated for  COVID-19 in intensive care units are sustaining kidney damage from the virus and require not just breathing support but also renal replacement therapy for their damaged kidneys — putting even greater strain on hospitals with insufficient dialysis equipment and trained staff. “It’s a burden of illness I’ve never seen before,” says Alan Kliger, M.D., a nephrologist at Yale School of Medicine. Kliger co-chairs a task force of nephrology experts across the U.S. who have been working at breakneck speed over the last two months to develop strategies for protecting vulnerable patients undergoing dialysis in inpatient and outpatient facilities and at home.

The challenges are immense: from finding safe transportation for patients going to dialysis facilities and ways of segregating dialysis patients who test positive for COVID-19 to procuring personal protective equipment and dialyzing solutions, which are in increasingly short supply. 

Kliger is on weekly conference calls with dialysis centers that once competed for patients and are now collaborating to move COVID-19- positive patients to dedicated facilities or shifts and sharing strategies about what’s worked for encouraging reluctant drivers to transport patients.

To be sure, the nation’s approach to managing care of patients with chronic kidney disease and ESRD was not working well prior to COVID-19. Well-documented failings — high numbers of uninsured patients, inattention to prevention and early intervention, and communication breakdowns among providers — already cruelly converged for people with chronic kidney disease (CKD) in part because the disease is asymptomatic in its early stages and screening is not routine.

Many patients only discover they have the condition when their kidneys fail, a phenomenon known as “crashing into dialysis.” A staggering number of those beginning dialysis — estimates range from 23 percent to 38 percent — start this way. This phenomenon is even more problematic in the COVID-19 era, when hospitals confront shortages of dialysis equipment and ICU beds. “I went to dialysis from the emergency room,” says Richard Knight, M.B.A., president of the American Association of Kidney Patients, an advocacy group focused on promoting early detection of CKD and expanding patient choice about treatment. “I hate to see someone go through what I did. We can do better.”

This issue of Transforming Care, researched prior to the emergence of COVID-19, looks at innovative models of care designed to identify people in the early stages of chronic kidney disease, engage them and their primary care clinicians in managing it, and prepare them to pursue home-based dialysis or transplants. It has arguably never been more important to slow disease progression and prevent patients from needing dialysis in inpatient and outpatient settings.

INNOVATIVE APPROACHES TO KIDNEY CARE

Slowing CKD Progression

One way to delay the need for dialysis or prevent it altogether is by better managing comorbid conditions that can damage the kidney, primarily diabetes and hypertension, and avoiding nephrotoxic drugs. The Indian Health Service demonstrated this is possible when it halved the number patients with diabetes progressing to ESRD by integrating CKD management into routine diabetes care. And a recent trial found that a drug used to control blood sugar can also prevent or slow kidney disease.

The National Kidney Foundation is providing information on the latest coronavirus developments for CKD patients.

And yet, many people with impaired kidney function don’t receive evidence-based care, often because it is not recognized early enough. Several health systems and startup companies have turned to electronic medical record systems as well as administrative claims data to identify patients early in the progression of their disease. Leaders at Intermountain Healthcare, a Utah-based integrated delivery system, were moved to act when an analysis revealed 70 percent of the health system's CKD patients were starting dialysis under emergency circumstances. Intermountain enlisted an artificial intelligence company to develop an algorithm that mines medical claims and records to identify those who may be at risk of developing or already have CKD. It also instituted standing orders to monitor renal function and deployed nurse navigators to educate patients; clinicians are also encouraging home-based dialysis and about half of new patients are choosing it.

Cricket Health, a five-year-old company offering a suite of CKD services to health care systems and payers, has also developed a machine learning model to identify people at risk of having undiagnosed or misclassified CKD. Its approach is based on medical claims data and does not require lab test results to deploy. Instead, it learns from the deidentified medical claims of patients known to have CKD, picking up signals that indicate problems. The algorithm also takes into account demographics, comorbidities, and social circumstances. Tests are then ordered to confirm disease. 

But even if their condition is recognized, many patients do not receive specialist oversight and their primary care clinicians may be unaware of treatment guidelines or too harried to provide them. Four organizations that serve a diverse group of patients — Parkland Health and Hospital System (a Dallas safety-net health system), Texas Health (a nonprofit health system), ProHealth Physicians (a Connecticut accountable care organization) and VA North Texas Health Care System (serving veterans) — are partnering in a trial testing whether use of technology and practice facilitators can help primary care providers support patients who have the dangerous triad of diabetes, hypertension, and CKD.

The trial is using PIECES, a decision support platform created by Parkland’s Center for Clinical Innovation, to form registries of patients whose lab values suggest all three conditions. Pharmacists or nurses acting as practice facilitators then help primary care clinicians deploy order sets that suggest medications shown to be helpful, ensure they avoid certain nephrotoxic medications, and help them track blood pressure and other lab test results.

Promoting Informed Decision-Making

Another key opportunity to improve CKD care is by offering education and support for people in the later stages, before their kidneys fail. Otherwise, they may miss opportunities to find kidney donors or make informed decisions about the dialysis modality that works best for them: in-center hemodialysis (used by 87 percent of those starting dialysis in the U.S.); peritoneal dialysis, in which the lining of the abdomen acts as a filter instead of blood being filtered outside of the body (used by less than 10 percent); and self-dialysis, a type of hemodialysis in which patients take charge of their own treatment either in a center or at home (used in a handful of places). Both peritoneal and self-dialysis are more common in some other countries, and some studies have associated them with better kidney function and other health outcomes, as well as improved patient experiences and lower costs.  Both options could also protect dialysis patients during the pandemic because they do not require going to facilities to receive care.

In 2008, Kaiser Permanente launched Optimal Start to improve patients’ transition to dialysis and increase the use of peritoneal dialysis. Patients and families were offered educational programs and opportunities to meet with staff, while nephrologists, renal nurse case managers, surgeons, and primary care clinicians were trained on the advantages of home-based dialysis over in-center dialysis. Part of this involved addressing misconceptions among clinicians about peritoneal dialysis, including that it is appropriate only for younger, otherwise healthy patients.

Kaiser Permanente set progressively higher targets over time, and the proportion of its Northern California patients receiving peritoneal dialysis rose from 15 percent in 2008 to 34 percent in 2018.  Most Kaiser Permanente patients (80%) who chose peritoneal were still using it a year later.

Helping Patients Navigate the System and Overcome Social Challenges

Several startup companies have stepped in to offer health plans a more coordinated approach to care for patients with CKD and ESRD, with savings generated in part by preventing avoidable hospitalizations and addressing social challenges — work that has become even more vital during the pandemic. Cricket Health offers CKD patients, generally at stage 3 or later, support from nurses, pharmacists, social workers, dieticians, and peer mentors. It has also developed an educational program that uses web-based modules, private chat rooms, and telephone support to help patients make informed decisions about their ESRD options.

Somatus, launched in 2016, also uses technology and analytics to identify gaps in care and deploys multidisciplinary teams — nurses and nurse practitioners, social workers, pharmacists, dieticians, and community health workers — to help patients manage their disease, make dietary and other lifestyle challenges, and address social barriers. Since COVID-19 emerged, these teams have been helping patients reschedule appointments and procedures and getting prescriptions delivered to their homes. 

Another startup company, Outset Medical, created the Tablo Hemodialysis System in order to simplify the process of self-dialysis. During the pandemic, demand for Tablo — which automates water filtration and offers touchscreen guidance — has increased as hospitals work to expand their dialysis capacity to treat I.C.U. patients who have sustained acute kidney injuries. Because the devices make their own dialysate to filter the blood (and thus aren’t subject to nationwide shortages in dialysate supplies) and because nurses can be trained to use the equipment in as few as four hours, the machines are in higher demand, says Tonya Saffer, Outset’s head of government affairs and market access. Hospitals have also been leveraging them to offer dialysis to less critically ill patients at alternative sites, allowing for social distancing among patients that is hard to accomplish in dialysis centers with less mobile equipment.

The U.S. Department of Health and Human Services now has a contract with the company to dispatch devices to states in emergency situations, and the U.S. Food and Drug Administration recently approved the device for home use, a move that could protect vulnerable patients during the pandemic and promote greater independence over the long term. “For now, the real focus is on how we support hospitals that weren’t prepared for such a surge in cases of acute kidney injury,” says Saffer. “It’s been amazing to see the ingenuity. In one location they were bringing OR nurses who aren’t doing elective procedures right now and training them to do dialysis.”

New Ways of Paying for Kidney Care

Led by Health and Human Services Secretary Alex Azar, M.D., whose father was a dialysis patient before receiving a kidney transplant, the Trump administration has pushed for reforms in how Medicare pays for kidney disease treatment with an eye toward promoting better outcomes and lowering costs. The federal government is instrumental in reforming the system because since 1972, Medicare has covered anyone who develops ESRD, regardless of their age.

Efforts to reform care delivery for patients with kidney failure began under the Obama administration in 2015 with the Comprehensive ESRD Care program, which creates special types of accountable care organizations in which nephrologists and dialysis centers can reap shared savings by better coordinating care, reducing medical complications, and increasing use of home-based dialysis.

To advance this work, the Centers for Medicare and Medicaid Services has proposed five new capitated payment models that offer incentives for providers to better manage care for patients during and before they reach the last stage of kidney disease. The goals are to slow the progression of CKD and to encourage later and better starts to dialysis and more and earlier transplants. These new payment models have yet to take effect and face pushback from some dialysis providers, who argue the targets for reducing in-center hemodialysis and increasing preemptive transplants are too ambitious.

LESSONS

The COVID pandemic is revealing, in painful relief, the cracks in our health care system and placing those with kidney disease at even greater risk. To protect them now and in the future, we can learn from innovative approaches. Doing so can save lives and money. “The majority of the potential savings from improving CKD care are likely to come from coordinating care, offering patients support, and delaying disease progression,” says Brian Brady, M.D., a Stanford University nephrologist who led an evaluation examining the practice attributes of nephrologists ranking favorably on measures of value. “And if we get patients on the right medications early in the disease process, we can stretch out the time they remain off dialysis. It costs an average of $90,000 annually per patient on hemodialysis. Every month we forestall dialysis initiation improves patients’ quality of life and creates substantial savings for the payer.”


 

Roundtable: Opportunities to Improve Chronic Kidney Disease Treatment

Delphine Tuot

Delphine Tuot, M.D., an associate professor of medicine at the University of California at San Francisco and a nephrologist at the Zuckerberg San Francisco General Hospital, has researched how to enhance patient–provider communication so that chronic kidney disease (CKD) patients are more aware of and prepared to manage their disease.

Transforming Care: Your studies have focused on how providers relay information about reduced kidney function. What have you learned?

Tuot: The language we use matters. In general, doctors are reluctant to use the word disease and aren’t often direct. They may say something like, “Your kidneys are not working as well as they should,” rather than, “You have chronic renal failure,” or “You have chronic kidney disease.” I think we need to coalesce around terminology that is more understandable and does not incite fear but is also truthful and encourages people to take action.

Transforming Care: Are there other reasons the message doesn’t translate?

Tuot: One is that it’s a lab diagnosis and a condition that’s asymptomatic until the later stages, so the diagnosis doesn’t make a whole lot of sense to patients, especially without an explanation of its cause. Also because until recently we haven’t had a lot of medications or interventions to slow progression, it’s not perceived as actionable, so it can fall to the bottom of the problem list during a 15-minute primary care visit — especially if the provider is trying to address five or 10 different things, like blood pressure control, diabetes, gout, and depression. Addressing all or some of those might actually prevent or slow progression of the kidney disease without the word kidney surfacing during the primary care visit.

Barry Smith

Barry Smith, M.D., Ph.D., is former president and CEO of the Rogosin Institute, a nonprofit dialysis and kidney care provider in New York City that performed some of the first hemodialysis treatment in the 1950s. In addition to providing care at all stages of kidney disease, the organization promotes wellness and prevention. It partners with community groups, churches, and other religious institutions to educate people about CKD risk factors and the nutrition and lifestyle changes that can reduce them.

Transforming Care: Rogosin relies on patient ambassadors — including people living with CKD and others who have donated kidneys — to deliver the message about the importance of screening and prevention. Why have you taken this approach?

Smith: We think that the message about better health and kidney disease prevention needs to come from people who live in the communities we serve and understand the local culture and challenges our patients face. We believe they will be more successful at encouraging people to get screened and getting them to consider dietary and other lifestyle changes. For example, we now have a group of clergy who are committed to talking about kidney disease to their congregations. One Sunday morning, after the sermon, we screened everyone at one church for some of the key indicators of kidney disease. Think about it. There are some 1,400 churches in Brooklyn. If we can partner with each of them to provide education about screening and prevention, we can make a huge difference. This is all about taking better health and disease prevention to where people are.

Transforming Care: What are some of the most common obstacles patients face?

Smith: There are many challenges. The people we serve have low incomes and confront the problem of keeping food on their tables. Some live in food deserts, where fresh vegetables, for example, are simply not available. At our East New York dialysis unit, a group called St. John’s Bread and Life brings a fresh vegetable truck to the neighborhood. They give out free vegetables not only to dialysis patients, but also to anybody who passes by. Many also endure poor housing conditions, which are a particular barrier to home dialysis. For home hemodialysis you have to hook up special plumbing and have the proper electrical capacity. Here in New York City you could have a $700 a month water bill. That is simply not affordable. For home peritoneal dialysis, we had a patient who asked if it would be OK to store her dialysis fluid supplies in the outside courtyard because she didn’t have space in her apartment. It was too small, and it was all she could afford. Speaking of financial difficulties, we had another patient who’d received a successful kidney transplant but stopped taking his anti-rejection drugs. When we asked him why, he said that he had made a decision that paying for his grandson’s crib was a more important investment than paying for his immunosuppressant drugs. He rejected his new kidney.

Richard Knight

Richard Knight, M.B.A., is president of the American Association of Kidney Patients, a patient-led advocacy group with a mission that includes educating patients, promoting early detection, and expanding patients’ treatment choices. A former hemodialysis patient, Knight received a transplant 13 years ago and wants to ensure that others have that option.

Transforming Care: Why do you think it’s important for patients to be prepared for dialysis and given different options?

Knight: I went to dialysis from the emergency room and there was no mention of home dialysis. The reality is the dominant players in the industry are in support of in-center dialysis. If you think about it, it’s easier to organize staff that way. The nephrologist can check on the patient when they are in the center and visit 15 patients in contrast to making 15 home visits. Recent innovations in technology have made home dialysis more feasible, and changes in payment have leveled the playing field between home and in-center dialysis, but it still doesn’t get explained sufficiently to patients. We always tell patients you will receive substantial training before you have to do it. And once a patient is taught how to work with the machines and use proper sanitary procedures, it is very empowering. One of the things the industry has to accept is that empowered patients are your best patients. Without it, depression tends to take hold and patients become accustomed to people doing things for them.

Transforming Care: Looking back, what do you wish had gone differently for you?

Knight: First, I want to say I am responsible for my own health and that there were certain things I could have done and should have, for instance knowing more about the impact of high blood pressure on kidneys. I actually found out from a urologist. He said, “Your prostate is fine but you’re in kidney failure.” I went from the ED to the hospital and into dialysis. I tell people instead of getting angry, I focused on how to get out of the situation. That’s why I am so adamant about educating patients. I always say if you go to dialysis go there with an exit strategy. One of the things that frustrates me is that patients are often encouraged to stop working and go on disability. For some that’s appropriate but not for everyone. When I was on dialysis, I continued to work. I was president of the Boys and Girls Club, and I was coaching soccer. Home dialysis would have been a great option for me, but it wasn’t as prevalent in 2004 as it is now.

Transforming Care: How does the American Association of Kidney Patients go about educating patients?

Knight: One thing we’ve done is to create a pocket guide that patients can take to their primary care physicians with a series of questions. We partnered with the Rogosin Institute and shared the pocket guide to help educate their patients. I don’t think we can depend on all dialysis centers to educate patients about alternate options. For the for-profit ones, their fiduciary responsibility is to their shareholders after all. Some dialysis centers, such as the Rogosin Institute, are going upstream to try to identify chronic kidney disease or the risk of it and prevent it. They are trying to drive themselves out of business.


Publications of Note

Improved Quality of Life for Medicaid ACO Members

A study of Hennepin Health, a safety-net accountable care organization (ACO) serving Medicaid beneficiaries in Minnesota, found patients with strong bonds to primary care, consistent mental health care, and support from extended care teams had improved quality of life. The ACO proactively identifies people who may be at high risk due to debilitating mental health problems, chemical dependencies, and life circumstances, including homelessness, and offers them care coordination services and social supports. Katherine D. Vickery et al., “Changes in Quality of Life Among Enrollees in Hennepin Health: A Medicaid Expansion ACO,” Medical Care Research and Review 77, no. 1 (February 2020):60–73.

 

Evidence-Based Treatment for Opioid Use Disorder Limited for Medicare Beneficiaries

Researchers found only 13.8 percent of substance use disorder treatment programs in 2016 offered medication-based treatment for opioid use disorder to older adults covered by Medicare. In contrast, 24.8 percent and 28.5 percent of treatment programs accepted Medicaid and commercial insurance, respectively. Access was more limited in rural areas. The authors suggest expanding the use of nurse practitioners and physician assistants for buprenorphine prescribing and enhancing access to treatment via telemedicine and federally qualified health centers. Samantha J. Harris et al., “Gaps in Access to Opioid Use Disorder Treatment for Medicare Beneficiaries,” Health Affairs 39, no. 2 (February 2020):233–7.

 

Virginia Medicaid’s Addiction and Recovery Treatment Services Reduce Hospitalizations

A study of Virginia’s Addiction and Recovery Treatment Services program, which expanded access to addiction treatment services for Medicaid beneficiaries, found it reduced the likelihood of having an emergency department visit within three months among patients with opioid use disorder (OUD) by 9.4 percentage points, a 21.1 percent relative decrease. In contrast, the likelihood of having an emergency department visit among beneficiaries with no substance use disorder was 0.9 percentage points lower. The likelihood of having an inpatient hospitalization also declined among beneficiaries with OUD. Andrew J. Barnes et al., “Hospital Use Declines After Implementation of Virginia Medicaid’s Addiction and Recovery Treatment Services,” Health Affairs 39, no. 2 (February 2020):238–46.

 

Bundled Payment Effective for Joint Replacement but Not Other Conditions

A review of studies of three bundled payment programs — the Acute Care Episode Demonstration, the voluntary Bundled Payments for Care Improvement initiative, and the mandatory Comprehensive Care for Joint Replacement model — found bundled payment maintains or improves quality while lowering costs for lower extremity joint replacement but not for other conditions or procedures. The authors recommend policymakers account for patients’ heterogeneity and include risk stratification for specific conditions in emerging bundled payment programs. Rajender Agarwal et al., “The Impact of Bundled Payment on Health Care Spending, Utilization, and Quality: A Systematic Review,” Health Affairs 39, no. 1 (January 2020):50–7.

 

Bundled Payment Program Reduces Spending with No Changes in Joint Replacement Quality

A study of the Bundled Payments for Care Improvement initiative, a voluntary program that bundles payment for lower extremity joint replacement, found participation was associated with a 1.6 percent differential decrease in episode spending with no differential changes in quality, driven by early participants. They also found patient selection accounted for 27 percent of episode savings. Amol S. Navathe et al., “Spending and Quality After Three Years of Medicare’s Voluntary Bundled Payment for Joint Replacement Surgery,” Health Affairs 39, no. 1 (January 2020):58–66.

 

Medicaid Expansion Increases Stability of Postpartum Care

Researchers found new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months after giving birth relative to their counterparts in Colorado, a state that expanded its Medicaid program. They also found that effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant complications during delivery. Sarah H. Gordon et al., “Effects of Medicaid Expansion on Postpartum Coverage and Outpatient Utilization,” Health Affairs 39, no. 1 (January 2020):77–84.

 

ECHO Care Model Shifts Care from Inpatient to Outpatient Settings

A study of the Extension for Community Health Outcomes Care model, which relies on outpatient intensivist teams to provide care to high-need, high-cost Medicaid patients, found it was associated with declines in hospitalizations and emergency department use. In the year after enrollment in the program, the odds of a patient having an inpatient admission and an emergency department visit were each reduced by approximately 50 percent, while outpatient visits and prescriptions increased by 23 percent and 8 percent, respectively. The researchers found no significant change in overall Medicaid costs associated with this model. The participants all had a chronic mental illness, and over three-quarters had a chronic substance use disorder. The teams, which typically included a nurse practitioner or physician assistant, a registered nurse, a licensed mental health provider, and at least one community health worker, received support from specialists who offer case-based mentoring on how to treat complex diseases. Miriam Komaromy et al., “A Novel Intervention for High-Need, High-Cost Medicaid Patients: A Study of ECHO Care,” Journal of General Internal Medicine 35, no. 1 (January 2020):21–7.

 

Allocation of Social Service Spending in U.S. Differs from Other High-Income Countries

Commonwealth Fund researchers found the U.S. spends far less than other high-income countries on benefits to support young and working-age people, like paid parental leave and early childhood education, but spends more on services to assist older people. Per-person spending on early childhood education and parental leave in the U.S. was about one-third of what other countries spent. The U.S. spent about one-quarter the amount on unemployment benefits for working-age adults as did other countries. Meanwhile, the U.S. spends $6,522 per capita on benefits like pensions, home health, and residential services compared with an average of $4,268 in other countries. Roosa S. Tikkanen and Eric C. Schneider, “Social Spending to Improve Population Health — Does the United States Spend as Wisely as Other Countries,” New England Journal of Medicine 382, no. 10 (March 2020):885–7.

 

Life Adversity Associated with Medical Complexity, Costs

A study examining the life experiences of Medicaid beneficiaries in Portland, Ore., with high medical complexity and health care costs found the greatest risk for both was associated with substance use, homelessness, childhood maltreatment, and incarceration. Those with the highest prior-year acute care utilization and cost had the highest rates of these same factors: substance use (62.5%), homelessness (61.7%), childhood maltreatment (55.5%), and incarceration (52.1%). David Labby et al., “Drivers of High-Cost Medical Complexity in a Medicaid Population,” Medical Care 58, no. 3 (March 2020):208–15.

 

Information Exchange Between Hospital and SNFs Doesn’t Lower Readmissions

Readmission rates among patients discharged to skilled nursing facilities (SNFs) that received medical record data from hospitals via an electronic portal were not significantly different than readmission rates of patients from SNFs without such electronic health information exchange. The portal was used for 46 percent of discharges, with significant variation within and across facilities. The authors suggest that use cases for health information technology need to be better defined and leveraged to achieve value in the context of transitions from hospitals to postacute care. Dori A. Cross et al., “Health Information Exchange Between Hospital and Skilled Nursing Facilities Not Associated with Lower Readmissions,” Health Services Research 54, no. 6 (December 2019):1335–45.

 

Trial of Hotspotting Program Finds a Null Result

A randomized controlled trial of the Camden Coalition of Healthcare Providers’ “hotspotting” program, which assigns a team of nurses, social workers, and community health workers to make home visits and coordinate follow-up care for patients in the months after a hospital discharge, found the program did not lower readmission rates for patients relative to a control group. The intervention also had no impact on the proportion of patients with two or more readmissions, hospital days, or mortality in the six months after discharge. Amy Finkelstein et al., “Health Care Hotspotting — A Randomized, Controlled Trial,” New England Journal of Medicine 382, no. 2 (January 2020):152–62.

 

Hospital-Level Care at Home Reduces Costs, Readmissions

Researchers found providing acute care at home — including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing to patients who would otherwise be admitted to the hospital, reduced the mean cost of care per episode by 38 percent. Compared to usual care patients, patients treated at home had fewer lab orders, imaging studies, and consultations. They also spent a smaller proportion of the day sedentary or lying down and were readmitted less frequently within 30 days. David M. Levine et al., “Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial,” Annals of Internal Medicine 172, no. 2 (January 2020):77–85.


 

Editorial Advisory Board

Special thanks to Editorial Advisory Board member Anne-Marie J. Audet for her help with this issue.

Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund

Eric Coleman, M.D., M.P.H., professor of medicine, University of Colorado

Michael Chernew, Ph.D., professor of health policy, Harvard Medical School

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, RAND Corp.

Allison Hamblin, M.S.P.H., vice president for strategic planning, Center for Health Care Strategies

Thomas Hartman, vice president, IPRO

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Lauren Murray, director of consumer engagement and community outreach, National Partnership for Women & Families

Kathleen Nolan, M.P.H., regional vice president, Health Management Associates

J. Nwando Olayiwola, M.D., M.P.H., associate professor of family and community medicine, University of California, San Francisco, School of Medicine

James Pelegano, M.D., M.S., assistant professor of healthcare quality and safety, Thomas Jefferson University

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, Dr.P.H., executive director, Center for Care Innovations

Mark A. Zezza, Ph.D., director of policy and research, New York State Health Foundation