Frank Diamond

In his long and distinguished career, the Brent James, MD, an internationally known health care expert, worked on both the insurance and provider sides. James is currently pushing a system called direct to business, which allows large employers and large hospital systems in a region to contract directly, cutting out the health insurer middleman. James recently sat down with 

 and provided examples of how such a system might bolster infection control and prevention. “Time after time, I’ve seen it dramatically improve clinical outcomes and reduce costs,” says James.

Direct to business arrangements. What are they? How they come about?

Why did they set up in the first place? You know, the best way I know to introduce it: Some years ago, I was asked to chair a strategic planning committee at Intermountain. Eventually it produced our population health initiative. In the committee, I had senior executives from across the system, including the three senior leaders from our own health plan, Intermountain Select Health, the largest commercial insurer in the region. Well as we were working our way through, I asked a question. I said: “Exactly how does an insurance company add value?” We came up with a list of 10 major items, there are lots of smaller ones just to give you a flavor for it. They do something called transaction processing, insurance claims processing—surprisingly difficult, by the way, real expertise around that. Actuarial risk analysis. Part of that is reinsurance. When you reinsure a patient. It’s for really high-cost patients. They did a certain amount of benefit design. They did a certain amount of customer support. Oh, a big one. They did network formation, where they found a sufficient number of hospitals, clinics, physicians to supply all health needs for the uninsured population. The list goes on. We did the analysis. The thing that we found is, number one, almost all of them were available as commodities in the general market. You could purchase them, outsource them, the claims process and the actuarial risk analysis, for example. You could purchase them at very good prices competently done in the external market. The only element that they couldn't outsource was network formation. But we realized that the system was large enough that it could form its own network. They had a sufficient blend of physicians and facilities that they can handle that on their own. The second piece, we came back next and said, “All right, given that this is the value add, how much should it cost?” We express it as percentage of the premium dollar. The answer we got was between 4% and 8% of the premium dollar. Seemed low. But I checked in our community. We had a number of nonprofit insurers. Desert Mutual Benefit Administrators, the DMBA, that’s the LDS Church’s self-insurance plan. PEHP, that’s the public employees health plan. It’s a consortium of public employee groups from around the state [Utah]. Educators Mutual, that’s for schoolteachers. They were all running at about 4%. That’s roughly where Medicare runs too, just in passing. It turns out the 4% to 8% estimate was pretty reasonable. Oh, the trick. Major for-profit insurers will pull somewhere between about 15% and 20% of the premium dollar to put on to their bottom line in the stock market. And it was that difference, let’s say between 6% and 18%. Twelve percent of the premium dollar is a lot of money. And that was the economic argument that if a large integrated system could go direct to self-insured employers, ERISA plans, that they could then through negotiation, decide how to divide that pie of 12% of the premium dollar. Now, frankly, given that it’s the health system that puts it together, and the health system that has to do the care management within it, I’m prejudice. I think it ought to swing a little bit more to the care delivery system side. But that’s what made it so very attractive. Now let’s shift gears and go to the other side, the care management side. A lot of insurance companies claim that that’s how they added value. That’s how they justified the additional spend. Fact is, we’ve proven that care management works much better at the level of the care delivery system than at the level of insurance. And we had our data showing that makes sense. It happens better if it’s closer to the point of action, where a patient interacts with the system, and the insurance companies are kind of two giant steps away. We knew that, “Oh, if you start to manage care, that’s where you get into the whole population health thing.” We estimated that we could drop the cost of care by 30% to 50%. So, you’ve got, let’s say, 14% here, but then you’ve got over here, you’ve got waste elimination to better care management. The cool thing about the waste elimination, the way you get it is to improve your clinical outcomes. The money aligns to your mission, better clinical outcomes, lower costs. And you’ve got an even bigger pot of money to share.

How does it standardize care and prevent defensive medicine?

Well, a classic. It was an infection control case. The patient went in for open heart surgery. He developed an infection, a post-op infection from a staph epidermidis, a common bacterium that lives on everyone’s skin and it’s usually completely innocuous. This was a strange variant. The patient had a very fast, bad course and died. Shortly after he died, his estate sued the hospital and the physicians because we didn’t prophylax that staph epidermidis. Turns out it was right in the protocol. They had a list of organisms that we did prophylax. They had a list that they purposefully did not. It turns out that we had the evidence based best standard. It doesn’t say you have to do everything. He just says that you deliver good care, and by consensus in our infectious disease staff, and the consensus among our physicians and nurses, that was best care. And what we did is we pulled out the protocol and then showed it to the plaintiff’s attorney. Once again, another lawsuit dropped fairly quickly before you go through all the trouble of preparation. That’s where the real money goes, by the way, in discovery and preparation. We had a long list of those cases. Now imagine the opposite happens. Imagine you have the standard, and you need to verify. All right, well, two things. We had built into every protocol, it was just boilerplate our attorneys have helped us with, it said this protocol is designed for the general use of most patients, but may need to be adapted to specific use of a particular patient by the patient’s caregiver. All right, it was right there in the protocol. It was honest, it’s exactly how we used it. It also became number two. That’s when you need the note. When you need that six-word note is when you choose to vary. You just need a clinical explanation, but it became a marker: “Oh, this is where I need the note to protect me.” You see, I have to tell you honestly on long experience, it reduced our malpractice risk because it established a legitimate written standard of care. And it told us in the document so on that our malpractice risk went down.

What about defensive medicine? That’s a big problem.

There are two elements to that too. The first was this. What turned out what was happening…. We investigated this a bit. So, you measure variation in care. one guy’s doing it one way, another person is doing it a different way. Third person’s doing it differently still, and we go back and ask him why, why did you do that? And nearly always they come back and say defensive medicine. It was a really common response. What we discovered, though, is it probably wasn’t defensive medicine that was just plain old garden variation. I was doing it in my opinion with very little support. Right. So, it was a marker for variation, and it probably wasn’t a legitimate answer. To be honest. It’s just a handy hook to hang your hat on when somebody challenges about why you’re doing this in this crazy way. You see, well, that kind of went away, but you have to give that pressure relief valve. On average, you know, we did this for over 125 protocols. You vary about 5% to 15% typically. I used to say it this way to my colleagues just to make it real easy: “Look, guys, we’re tracking protocol brands. You will get as much scrutiny for complying with protocols as for complying too little. If you’re different from your colleagues, we want to take a look. The first time that really played out was in infectious disease interestingly enough. John Burke, the head of infectious disease, had a system. If you had an inpatient who developed an inpatient infection, it was like he got a console from ID in about three or four seconds. You just called up the program. You had to tell it the sites of infection you’re interested in, but then it did an epidemiologic evaluation of that patient. The first screen listed: Here are the most likely causative pathogens in our experience at this hospital. It gives you a differential of causative pathogens. There’s a 72% chance it’s this one. Oh, with this pattern of sensitivities, there’s a 59% chance it’s this one. There’s a 31% chance with this one. With each sensitivity in probability order. If you went one screen ahead, it said, here’s the best antibiotics to treat this set of infections. It actually gives you several choices. It was in priority order by efficacy number one, and then if it had several similar efficacies, it prioritized them in cost order. And if you saw one you like, give me a number two. It ordered the drug, it alerted the nurses. If you had level testing, it automatically did the level testing. Now initially, people were really kind of watchful around this thing. Did it deliver good care, as you would expect from any good group of clinicians. But it turned out to work and it worked pretty well. The real problem is, oh, two months later, they came to us and said, “You know, we don’t really need to see the differential. Just show us a list of antibiotics. It will shorten our time.” And then they came back and said, “Don’t show us the whole list of antibiotics. We pretty much always want the one on the top. Just show us the top one.” It reduced it to a single click, single return. And it took the time that when I was practicing surgery, it used to take me 10 to 15 minutes. It probably cut it by half. You see, that was really popular. But then we saw the downside. The downside was John Burke, using the same system, started to pick up cases where they should have buried, and didn't. It made it so dang easy to follow the protocol that, you know, people aren’t thinking as hard as they should. But it turns out the same system that detected it…. At the time at LDS hospital, you might get a console from ID even if you didn’t order one. Because John Burke was monitoring the whole hospital and he’d come by on cases that looked like they needed a little expert oversight and just show up. They learned how to interact with their colleagues in a positive way. What we saw—by the way, this was published in 

—was a rather dramatic drop in…. Well, it was infection related mortality was what they were tracking in that study. And side-by-side with it, a drop in costs. I love the way that one of our ID docs said it. He said it was more targeted therapies where you were getting the right therapy to the right patient at the right time.

You know, I’ve been looking for my whole career for things that make this happen faster and better. Time after time, I’ve seen it dramatically improve clinical outcomes and reduce costs. Sometimes it’s a real uphill fight. And frankly, on my side, it mostly has to do with administration worried about the revenues. When you move into these straight to business relationships, technically, it’s a form of shared savings, and it solves the financial side so that medically we can do what’s right. And I’m pretty sanguine about it. I like it a lot. I think it’s a good way to practice medicine that will make us better doctors, help us learn faster, and help us deliver dramatically better care to our patients. I hope it takes over the world. I think it will make us better doctors and a better practice in general.

Oh, yes. Oh, yes. The examples I just used were all infection, weren’t they?

This interview has been edited for clarity and length.

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Brent James, MD: “If you had an inpatient who developed an inpatient infection, it was like he got a console from ID in about three or four seconds. You just called up the program. You had to tell it the sites of infection you’re interested in, but then it did an epidemiologic evaluation of that patient.”

Q&A: How Direct to Business Coverage Can Help Infection Care

Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today. Each column explores the Bug of the Month's etiology, the infections it can cause, the modes of transmission, and ways to fight its spread. The pathogen profiles will span bacterial, viral, fungal and parasitic species. We encourage you to use Bug of the Month as a teaching tool to help educate healthcare personnel and start a dialogue about microbiology-related imperatives.

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Bug of the Month helps educate readers about existing and emerging pathogens of clinical importance in healthcare facilities today.

Bug of the Month: I Can Be Deadly for Cystic Fibrosis Patients

Infection preventionists are needed to help schools reopen properly, says Kevin Kavanagh, MD, a member of 

’s Editorial Advisory Board. Kavanagh worries that the push to reopen schools may be setting society up for a new wave of coronavirus disease 2019 (COVID-19). And even before COVID-19 hit, Kavanagh points out, schools were not safe havens for children. They’re more like germ factories. “Our schools in many areas are just plain dying, their infrastructure is crumbling,” says Kavanagh. “Their windows don’t open. The air really is not safe…. They are not healthy buildings.”

Doctor Kavanagh, you’re writing an article for the October issue of 

 about some of the problems involved in trying to reopen schools in the midst of the COVID-19 pandemic. What did you find out?

Well, one thing is, is that we really do need to pay attention to the science, and we need to guard our children. That’s probably two of the most important factors. There are too many that think well, we can just open up schools and we don’t need to do much different rather than putting our children in school because they’re very low risk. Well, there’s two factors which I think you need to realize. One is that the children do become infected with the virus almost as frequently as adults and they can spread the virus. They’re just asymptomatic carriers. One study found that approximately 80% of children who are infected with the SARS-CoV-2 virus are asymptomatic. But that does not mean that they cannot spread it to their parents and guardians who are looking after them. And also close to 24% of teachers are at high risk for developing COVID-19. The second factor is that even though children are not at very high risk of dying from COVID-19, they still may develop long-term effects from this virus. And this includes those that are asymptomatic carriers. In children less than age 19, only about 2% are hospitalized. But even those children, in children who are asymptomatic, may be at risk for long-term damage and effects on their heart. It’s not likely to happen, but it certainly can. As you know, we have recent reports out of Penn State that up to 15% of college football players who tested positive for COVID-19—and this includes both symptomatic and asymptomatic patients—has a mild carditis. And this may present many years down the line with a cardiomyopathy. Now you’ll hear people say, “Well, we don’t know what that means. They’re asymptomatic, so they probably won’t develop anything.” Well, the problem with that narrative is, is we just don’t know. And dilated cardiomyopathy, which is the most common type, almost 50% of those are idiopathic, or you do not know what caused them. And it’s felt to be caused by an asymptomatic, viral myocarditis. And so, this is cause for concern. And as you know, children can also rarely develop that Kawasaki-like disease, which can occur in approximately 1% or less of those that develop COVID-19. And that is a severe illness and can be very, very life-threatening.

 for our October print issue, you also write about how school buildings in general aren’t really safe for our children.

Well, that’s correct. Our schools in many areas are just plain dying, their infrastructure is crumbling. Their windows don’t open. The air really is not safe. Even before COVID-19, it was well known that if your child goes to school, you may well get more colds and also could come down with the flu. They are not healthy buildings. We do need to take this time and upgrade the infrastructure of our schools. This includes bigger classrooms, more hand-washing stations, but also better circulation of air, filtration of air, and cleaning of the air. Look what the airline industry has done for airplanes. They place a number of people inside a small metal tube, but rarely are you hearing about them getting infections. Why? They have excellent circulation of air, excellent cleaning of air, they require everyone to wear masks. And whenever possible they are employing social distancing. The same needs to be done for schools, wearing of masks and social distancing—not and/or—but both. And social distancing needs to be a minimum of six feet. One of the things we’ve learned about this virus is that under certain circumstances, it can aerosolize and this includes loud speech, actively screaming, talking loudly. And in that case, cloth masks and the six-foot rule may not be enough. And this is the reason why you also need a variety of interventions, including upgrading the school’s air systems.

I think that the US Centers for Disease Control and Prevention has guidelines for office buildings that are refurbishing in terms of their airflow to make sure they’re safe before they open, is that not the case?

I believe that is correct. And the same should apply for schools. It really is crucial. We need to pay attention to the infrastructure, we need to learn to live with the virus. Now some will say, well, this epidemic will go away. Well, you know, it really doesn’t matter. Our children are our most precious asset, they should be in a healthy environment. And if it cuts down on the spread of the flu, the spread of colds, of other pathogens, that investment will be well worth it. This is something we really need to do. And we need to open up schools at a time when it is safe to do so. What I mean by that is a community spread of the virus needs to be low and currently we are getting into almost an untenable position where neither alternative is good. Where students stay home, and they will possibly suffer psychological damage and loss of socialization skills. Or if they go to school, it’s too risky. And all of this is a result of society not following public health advice and driving down the community infection rate and our test positivity rate to less than one. And I’m saying less than one. You will hear less than five. But that is a bare minimum, the number five. New York City is having trouble opening up schools, and their test positivity rate is less than one.

Who would oversee the refurbishing of schools?

I would think it would be under the state departments of education. If you go into local governments, it’s going to be really a whack-a-mole approach with different standards everywhere and the virus doesn’t care. It’s not different everywhere. It is the same entity. And strategies that work in one place will work in another and strategies that don’t work in one place won’t work in another. And certainly, it’s going to require grants, either state or federal funding in order to get this infrastructure up to speed. And this will also stimulate the economy. Similar to going to war with an outside adversary, believe me, this virus is the same thing. We need to really invest in infrastructure, not only in schools, but office buildings and restaurants. All of this will require money. I think state grants would be great. And I also think that that’s a way to stimulate our economy, let alone increase the safety of our children.

Do infection preventionists fit in this scenario at all with schools and school safety?

Well, definitely. I think you’ll find that infection preventionists in this type of climate are just not healthcare employed personnel. They need to be everywhere. They need to be in business. They need to be in schools. And, of course, they need to be in our healthcare system. But it is crucial to be in schools, to advise schools on the type of restrooms to have, on the type of social distancing, on how to set up a cafeteria, on how to filter air, on the type of PPE needed. And we do need to get the same quality of PPE for our teachers that is available for healthcare personnel. So yes, we need to look at this as not a healthcare problem, but as a societal problem, and infection preventionists are absolutely key in getting us back on track, both with the economy and getting us to be safe, as safe as we can be when we leave our homes.

Kevin Kavanagh, MD: “I think you’ll find that infection preventionists in this type of climate are just not healthcare employed personnel. They need to be everywhere. They need to be in business. They need to be in schools. And, of course, they need to be in our healthcare system. But it is crucial to be in schools…”

Q&A: Infection Preventionists Should Head Back to School

To meet unprecedented expansion needs, the Children’s Hospital of Philadelphia (CHOP) revamped its infection prevention team by adding more staff and making sure that the staff had a diversified background. This resulted in a 23% decrease in healthcare-associated infections (HAIs) between 2014 and 2018, according to a study in the 

. This reduction in HAIs occurred even as patient days, central line days, ventilator days, and device utilization increased each year. Investigators with CHOP noted that HAIs account for about 72,000 deaths each year in the United States, roughly 1 in 31 inpatients.

CHOP investigators also note that the role of the infection preventionist (IP) has grown in recent years, thanks in part to state and federal mandates concerning the reporting of healthcare-acquired infections (HAIs). This focus on HAI surveillance diverts the IP’s attention away from other infection control duties.

“In addition, IPs have a more prominent role as frontline responders to public health emergencies related to both emerging and re-emerging infectious diseases, such as pandemic H1N1 influenza, Ebola virus disease, outbreaks of vaccine-preventable diseases (eg, measles) and rising antimicrobial resistance,” the study states. “Furthermore, device-related outbreaks, such as those associated with contaminated heater-cooler units and duodenoscopes, require prompt investigation and resource-intensive responses. The latter have underscored the need for enhanced infection prevention and control (IPC) oversight and increased regulatory scrutiny of high-level disinfection and sterilization programs.”

CHOP created a 3-tier career ladder for its infection preventionists and drew equally from nursing, public health, and laboratory scientist backgrounds. Using a framework developed by the Association for Professionals in Infection Prevention and Epidemiology (APIC) that recognizes novice, proficient and expert IPs, the CHOP career ladder consists of Infection Preventionist I, Infection Preventionist II, and Senior Infection Preventionist. The IP staff grew from 4 to 9, and added the additional support roles of hand hygiene program manager, infection prevention associate and a clinical practice analyst. These changes expanded the education and consultative range of the department, as measured by a 33% increase in environmental rounding and a 7-fold increase in performance of isolation audits.

“The core strategies we chose to implement were to increase staffing due to organization growth, create career ladders to recruit and retain talented IPs and to add cost-efficient supporting team roles,” the study states. “These strategies will allow our team to keep pace with the rapid expansion of our organization and growing complexity of the field, while continuing to promote safer patient outcomes.”

Investigators with CHOP developed an algorithm for 5 key HAIs: central line associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), ventilator associated pneumonia (VAP), and healthcare-associated viral infections. There was a statistically significant reduction in rates of harm across the 5 key HAIs, the study says.

The study states that CHOP’s infection control department takes the novel approach of providing supporting roles in infection prevention, which can serve as “entry level positions for future IPs while providing cost-effective support for the needs of the program. Diversifying roles and creating support staff benefits the team by increasing the productivity of the department and providing a deeper bench so that IPs can focus on broader activities requiring specific subject matter expertise. In addition, this staffing structure engages employees in career development in alignment with the APIC competencies to support retention and increased employee satisfaction….”

Diversifying roles and creating support staff benefits the team by increasing the productivity of the department and providing a deeper bench so that IPs can focus on broader activities requiring specific subject matter expertise.

Author | Frank Diamond

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Q&A: Infection Preventionists Should Head Back to School

Expanding Size, Variety of Infection Prevention Team Pays Off