to be or not to be

I am torn, as this week winds down, between desperately wanting some health reform to go through and realizing that without a public option, some cost controls and expansion of Medicare, I will be supporting a bloated and insolvent system into the future. The insanity of the politics right now lead me to believe that a bill needs to go through no matter what since the arguments opposing health reform are so circular. The same folks that oppose government health care, oppose any cuts to it.

So, I am leaning toward passing the reform measure, complicated and more than a compromise, because it opens the door to continuing the movement toward real change. If the door closes now and there is a move to scrap and start over, I believe that history shows that it takes about 10 years to get it back on the table. The public is usually so confused and forgets until the next economic crisis how difficult the healthcare structure is to maintain.

I sound like a progovernment liberal. I am liberal, but having been in healthcare and more importantly having lived for almost 25 years in Illinois, I am not blindly pro-government. I am however, pro- getting the goals right and then the charter language that ultimately drives the design right and get to the details later. Right now I don't think the private sector can take the high road on having the goals or the guiding principles right. So it is a toss up and I am tossing my cards toward "the beginning of change is better than none".

Trends I hate

This is just personal venting. I hate camera phones being everywhere. Its creepier than the satellite mapping my front door (big brother!). It seems that everywhere you go and everything you say has to be screened - forget spontaneity. Every audience has a potential coward who wants to catch your thoughts for sound bites- not to have a legitimate debate or respectful discussion but as a gotcha. Every party has an opportunitst that would love to catch you talking with your mouth full! It just seems so intrusive - a technology gone awry! I feel the most sad for my teens where every thought is on facebook and every mistake is caught on camera for all the world to enjoy...

And I hate the self righteousness of those who throw them in your face and act surprised and superior when you are defensive and unresponsive. So next time you think its your "right" to capture what is being said, maybe you should think about listening to the speaker instead and keeping your phone in your pocket.

Luckily this is not about me....its bad enough watching it happen to others! So what do you do...as one of the Sisters I used to work with said to me....always speak from the heart and you don't have anything to worry about.

2009 Countdown!

The Top 10 most memorable moments of 2009


Number 10 -Ironic moments in reform: Medicare recipients marching on townhalls protesting Government run healthcare with slogans like "Keep your hands off my healthcare". (Anti abortion activist (Rep Michele Bachman) use "keep government out of your healthcare decisions".

Number 9 - Bizarre moments in healthcare reform: Public option taken off the table in favor of the private system that has left 44 million people uncovered.

Number 8 - Sad moments in reform: Senator Kennedy's death during this historic debate.

Number 7 - Illogical moments in reform: Republican deficit hawks complain about "rationing" (evidence based medicine) as Medicare sinks deeper into insolvency. And Kathleen Sebelius can't support evidence based mammogram screening.

Number 6 - HINI declared pandemic - pictures of lines to get vaccines and people wearing masks in Mexico.

Number 5 - "Hellohealth" model and e patient healthcare getting attention from big players.

Number 4 - Senate approves economic stimulus bill which focuses attention on health IT incentives

Number 3 - Health bill passes house; first since Medicare

Number 2 - Bills make it out of Senate finance committee and Public Option is scored neutrally.

Number 1 --Hopefully we will see it in the next 15 days!

"The only thing I know for sure.....

is that we will be paid less." The quote by Jim Skogsbergh of Advocate Health In Crains Chicago Business seems to hit the nail on the head. Are your key strategies driving to significant cost efficiency?

More on e-patient

http://www.slideshare.net/NCurse/practicing-medicine-in-the-web-20-era-1207689?src=embed
RSS feed, google calendar, google health, pharmasurveyor.com, medting.com, webicina.com, pubmed searches, podcasts, hellohealth.com, ozmosis, linked-in physician searches, twitter, wordpress virtual education, genomic data, skype and webcam communication.

If there is anything on that list that you are not familiar with, sit down with a medical student and get an orientation.

The link is a great introduction and the most important comment in that slideshow is that the epatient will drive use of technology! Not your systems or your physicians. Check it out.

Ambulatory Care....its the patient stupid!

Trinity just reorganized their top staff to focus on ambulatory care. Ascension assigned a Senior Executive several years ago. Advocate has moved aggressively to organize their physicians. So what will all this effort, geared toward the new health reform agenda (or the old managed care model) need to focus on.
Ask the patient....as noted on his blog and on Health Leaders Media renal cancer patient David deBronkart took control of his healthcare in partnership with his doctor. He was an e-patient...finding his own answers and questions. What do epatients do? According to epatient David:
They look at their medical records online
They may share medical records with family and friends who know medicine
They use e-mail to correspond with their doctors
They are active partners with the various physicians involved in their care
They're often active in patient communities
They may become active researchers

and they walk if they can't get that kind of access!

This time it really is about the patient, not the institution. This may be the first real market the healthcare industry has ever really faced. And we do not know how to be patients as much as we try. We need to ask.

Where are you on your physician integration strategy

The mere fact that a system is investing in EMR/EHR with subsidizies to physicians to the tune of $400 million is breathtaking enough. But how does that change the landscape for everyone else? The greatest reform/transformation of practice will come from coordinated networks of care with information to effect evidence based change in practice. (I know I have been around awhile but doesn't that sound like a closed model HMO in development.) In any event, its coming to your town and if you aren't the financially strongest system then you are going to be chasing the wind trying to close an increasely difficult gap.

That system is North Shore Long Island Jewish but other large and well funded systems are following suit. They will tie physicians to them in a way that you won't be able to break. They will effectively create networks of medical homes.

If your capital is not going into IT and physician IT you are spending dollars on technology that may not get used!

The relaxed Stark laws are a gift that is good for the patient and for the system that moves with deliberate speed.

Culture wars....

A consulting colleague of mine told me of a story of how he fired the client! Not that the work was not rewarding, but that the culture was so disfunctional - at the top - that it had permeated the lower levels. Got me thinking about all the leadership traits that we ignore when someone is "getting results" - and the legacy that they leave behind.

Lots of leaders have arrived in organizations needing turnaround and after a year of planning, identifying the leaders that will stay and those that will go, they start mumbling about how the culture needs to change. And then they repeat the mantra that cultures take years to change...
so what is a leader to do!

If it looks like a bully, it is a bully - get rid of them. If it looks like an obstructionist, it is an obstructionist - let them obstruct someone else. Don't expect the frontline to treat patients with respect when they are not treated similarly. Make some visible changes and be as transparent as possible (confidentiality is important I know) that the culture is about vision, goals, measured performance, innovation etc and does not have room for brute force or road blocks at the top. Be clear about who is taking their place.

So in the short term:
1. Visible style changes
2. Repeat and focus on what is most important to change (rapid implementation, budget, service) - pick one
3. Measure, measure, measure -everyone to that standard
4. Evaluate and celebrate the change - With what counts - promotions, salary, bonuses, days off...etc. Incentivize the change.

I know one disgruntled employee of a fortune 50 company who was taken over in a "merger". He was a lucky one who kept his job, but felt betrayed by the merger. He grumbled a bit, but did his job well. When the year end bonuses came out for performance and they were twice the size of the previous company; his grumbling went into the closet. When it happened again, the grumbling stopped.
The moral- they won't love you for change but they will go along if you practice what you preach and you reward those who go for the ride. Let them know why they should follow you.

Is Population based planning in your best interest?

The Washington Post article this morning on the CBO's estimates on the various reform bills had me thinking about the lack of population based health planning used by hospitals. See http://www.washingtonpost.com/wp-dyn/content/article/2009/10/18/AR2009101802541.html?wprss=rss_politics .

Why do I think hospitals should care other than to sound intelligent in the healthcare debate? Because without that counterbalance to your strategy, you are following the lemmings off the cliff. Its like the recent housing market, subprime lending and all the other wonderful ideas. How many of us have started the 'center for this and that' because it was a great money maker. What happens when that money maker is no longer the economic driver, the primary care practice is.

Okay okay, you do environmental assessments as part of your strategy. Why is that not enough? Because if the paradigm shifts, and the model really does change, where are you? Do you know the cost per capita in your community (without looking it up). (I bet you know your bottomline and your numbers of deliveries without looking them up). Do you know fertility rates and cancer rates by race, age sex and zip? Do you know beds per 1000 in the community, bed days per thousand residents, back surgeries per thousand residents? Cardiologists per capita, PCCs per capita. The insurers do, the government does and if you are in an overbedded or competitive market watch out when reform begins to roll out if you don't know.

Do you know the performance of your medical staff on diabetic protocols and other protocols for chronic disease patients? IF your doctors are not compliant and know it, do you think new diabetics will chose them?

Food for thought on a Monday morning.

If you didn't hear it you know it anyway!

NPRs story on doctor practices in Vermont and Maine. Surprised that practices differ and there is no objective data to support it. The only data was what is paid for and the outcomes...Yup you guessed it, more did not make the population healthy. More back surgeries, worse outcomes.

I think we all know it. But what does it mean for us going forward.
1. Payment incentives need to radically change
2. Outcome data needs to be shared with patients -not comparing providers but what does this mean for the patient in terms of quality of life, length of life, disabilities, etc vs other treatments
3. Healthcare needs to be system based not hospital driven. There is no system now with few exceptions. Where there is utilization is lower with no negative health outcomes.

Are you surprised?

Insurers don't like any provisions that lessen the individual mandate? Wouldn't we all like mandates for individuals and corporations to buy our products. And if we don't they will raise their rates? So that is how capitalism works? I thought it was the opposite. If they don't buy your product you lower your rates! I am being drawn back in my thinking about how the market doesn't work in healthcare (HBR article a few months back) - there is no upside incentive to materially cutting back on the cost of services. It is the most expensive services that are used more to make up the slack in revenue and then the insurers pass it on with their slice.

Mmmm....350+ lobbyist descending on Washington. One per elected official. Wonder who wins this debate!

So where does that leave the public option. The Dems seem to have backed themselves into a corner with a good financial score on the no-public option option....where do they go from here....Clinton all over again?

Real income growth to pay for health care

Health Affairs this month is all about cost...
" 53.6 percent of real income growth over the period would go to health care. Moreover, even with the more favorable assumption, the nation would still face important challenges paying for care".
Just think of that over half of every new dollar earned by Americans will go to their healthcare. How long do you think they will put up with it? If you aren't the lowest cost provider in your service area now, you are going to have some explaining to do. And what if they start to tax those dollars.

Technologies and systems that reduce per capita expense is what leadership needs to be about. Do you even know per capita expense in your community? Does your board?

All dinners start with rationing....

Very nice well dressed people gathering for a break fast feast ran out of movies and veered to rationing within 5 minutes of sitting down to dinner. Because it was a social event and not a scream fest at some town hall, everyone smiled and worried about how they won't get all their CT scans if reform goes through. They talked about the hippie public health types being interviewed who brought up all the moral justification.

Okay, for the record, moral justification in this country only works for little children. Adults are generally supposed to fend for themselves and even most juvenile offenders are treated as adults these days. SO forget the moral argument.

And forget the rationing. Change the incentives for physicians and hospitals to practice sound scientificly based medical care and there will be no need for rationing. You won't need to worry about all the radiation from your sixth CT scan because someone might actually have looked at the last three. Read the attached link...

In Delivering Care, More Isn't Always Better, Experts Say
» Links to this article
By Ceci Connolly Washington Post Staff Writer Tuesday, September 29, 2009

What will we talk about next time, "less is more".. Rationing is sexy face it!

Rookie docs talk reform....

Okay its from the Huffington Post so its on the liberal side. But it is interesting to hear from Residents and Medical Students - Check out the link. http://www.huffingtonpost.com/youth-radio-youth-media-international/rookie-docs-talk-health-r_b_292086.html

If you have ever been told that everyone can get emergency care, just read this link. As you well know, ER without drug coverage, primary care or followup specialty care doesn't get you very far and is a very expensive plug.

Are we having fun yet?

Monday, September 21, 2009

With the downturn in the economy, all my colleagues are facing cutbacks and projects slowed down. They are working harder with less. The cutting edge folks are facing budget cuts to their R and D budgets.

So how will innovation occur that will actually save all that money?

It will not occur in a vacuum or at the pace of normal healthcare innovation. Look around, there are loads of new ideas.

Let's have some fun. A treasure hunt. Let's start with a question?

Do you know where to find Docs? No not in a hospital...how about on google? No not medical docs, free floating documents on google docs.

What info have you been dying to get your hands on from your senior staff this week but don't want a meeting....try something new.

Go to Google. Sign in (takes one minute or less to sign up - free too!) Go to Docs. Press New. Press Form. When it opens - title it something important - Like Mandatory Data Request!!! Then give wonderful instructions like "I need by 5pm. Fill in all required fields."

Then go to town. Asked for anything. (Where the sample question box is) - Be creative: "What is the leading safety concern of staff today in our ICUs". As soon as you type it in it gives you another box! Yippee! Now you can go crazy on the next one. You can even give them a selection....check boxes or multiple choices, etc. They can even rank something! What are you wasting meeting time on this week that you senior staff can just get you the data today?

Keep it short for your first venture.. Don't get so carried away that they take you away by afternoon!

Now if you are not having fun with this, its because your creative juices are just starting - so go to Theme and pick one. You could go serious so that your team knows you mean it or you could go fun to get their attention. Just pick one. Then pick see responses so that you can see that all your responses will either be graphed or put in a spreadsheet for you so you can just look at it at 6pm on your way out the door!

Now you have to "share" Just load in the folks you want to give you info. You can always email it to them, but sharing is nice too.

Now in case you are feeling guilty wasting your time on the internet think what you just learned:
1. Creating data is extremely simple in this day and age and you should be getting it realtime.
2. You now have a google account so you are in this millenium.
3. Your managers could be getting data from their frontline people on any problem area at any time.
4. You can focus attention rapidly without a meeting. The new kids on the block are not going to tolerate our long agendas.
5. You have created transparency among your team by sharing...not for competition but for "signing on to each others success" -

I hope you had fun. More soon.

PS. You can get estimated revenue variances this way too! Daily!

Reform debate....do your staff have the facts?

Two nurses had a heated hallway debate recently on whether socialized medicine (if it were only so) was going to become a reality under this administration. One nurse loudly proclaimed the evils and the panels that would be overseeing and restricting care, pointing toward the rooms where elderly cardiac patients, many of whom had just had a procedure rested hooked to monitors. The other nurse equally loudly proclaimed how broken the current system was and how she trusted Obama to fix it.

Wow, was there alot in that discussion - besides how inappropriate it was in the hall with patients in earshot who were overwhelmed with their own current issues. It would be helpful if we could get facts out to our employees on this very important issue. We are not going to get the hallway debates to end, but we might be able to take a small step for mankind in moving the debate forward.
Let's break it down shall we:

1. Panels - Death or otherwise. Many people without insurance or those with inadequate insurance (that may be more than we know) might say that they already experience rejection from needed and life saving procedures. They definitely will tell you that quality of life issues are already on the economic table. Will a government affilliated panel be that much worse?. I personally believe that they will act more like our current hospital P and T committees (remember formularies) or the way Medicare does now.

2. Payment for end of life considerations and education. This is only the tip of the iceberg of the discussions, and time, that primary care doctors should be educated about and participating in. For anyone who has gotten on an airplane thinking a sick relative is recovering, only to get a call a couple hours later asking you to decide not to intubate, the idea of a face to face discussion in advance sounds like a good thing. Let alone the poor patient suffering through unnecessary intubation and extubation only to die a few days later in a coma.

3. Can the government be trusted to run anything without gaming it? I think we can agree that gaming the system is not only the purview of government! Having said that, the idea of a having a group of commissioners oversee seems not only sensible but critical. Let's get the criteria right for the commissioners instead of debating the need for government to take responsibility for a segment of the population.

4. From the sound of the debate, it seems that there is a loud minority who do not believe that the current system needs fixing. Have they been sick? Have they never had a safety issue, have they never had a wrong test or missed diagnosis or 12 page long bill or stack of bills from so many doctors, many whom you never met? Have they never met an uninsured patient or someone who could not afford to pay hundreds of dollars per month for chronic disease medications?

5. One size doesn't exist for everyone now with private insurance. Care for the poor is different state by state; payment is often not received by the doctors in Illinois for months on end. When those doctors choose to no longer take poor patients or better yet, to no longer take any form of insurance - will that be the status quo that we are protecting by rejecting reform.

6. The trillion dollar budget deficit contributed to by the new plans sounds like a real issue. Do we think that this is new cost. Do we think that folks aren't accessing care now but in the most convoluted and expensive ways with long term consequences. Do we think Medicare will be reformed to stay solvent without someone overseeing the system and redirecting the wasteful way that we consume healthcare dollars.

7. And when the plan says that care for undocumented residents may be available but will not be subsidized, that means that the government is not providing care for illegal aliens. If care was not available to those who come to our country from abroad, just think of yourself on a trip oversees and needing care.

Some facts of what works and what doesn't might help healthcare employees navigate the debate and help others see the system for what it can do and could do. If you don't agree with my facts, share some real ones.

And by the way, whether the number is 50 million at some point in a year that are uninsured or 8 million as my father believes, it is too many. One close relative is too many. An entire community is too many and millions are too many.

Personal EMR primer

Harvard Business Review's article Your Medical Information in the Digital Age
by John D. Halamka, MD is a great primer....see the following excerpt. What more can I say, so I didn't. The following is from the HBR article.
"So far, four types of electronic personal health records are available:
Hospital- and clinician-hosted records are great if all your information resides at a single institution. One example is PatientSite, used by more than 40,000 patients of Boston’s Beth Israel Deaconess Medical Center to view their hospital records, send secure e-mails to doctors, make appointments, refill prescriptions online, and the like. But this kind of service is not widespread. A recent study in the New England Journal of Medicine found that only 9% of the acute-care hospitals surveyed had an electronic-records system in place in even one clinical unit.
Payer-hosted records, such as HPHConnect from Harvard Pilgrim Health Care, give you access to claims information relating to your medications, doctor visits, and hospitalizations. Some let you share information with family members or doctors. On the downside, you may not be able to access all of your lab and radiology results, and there’s no guarantee that you can take your record with you if you change insurers.
Employer-sponsored records are typically hosted by a trusted outside firm, creating a firewall between the employer and the medical data. For example, computer storage giant EMC partnered with WebMD to offer claims-based personal health records to all of its employees. Employer-sponsored systems aim to keep you healthy and productive by, say, recommending an exercise program if you are overweight. They can also help you manage your health care–spending account. However, you may not be able to take yours with you if you change jobs.
Commercial offerings, such as Google Health and Microsoft Health- Vault, allow you to link to your electronic records stored at participating hospitals, pharmacies, and laboratories. In addition to collecting existing data, you can add your own, search for information about medical conditions and drug interactions, and share information with your doctors and other appropriate parties. These services let you keep your health record for life, regardless of your job or insurer. Google recently implemented secure “social networking” for personal health records. Call it Facebook for health care. It allows you to invite caregivers or family members to access your personal health information. Invitees can be removed at any time."

Competition creates no net value currently

Michael Porter and Elizabeth Olmsted Teisberg in the current issue of HBR on competition is important reading given the progress of reform http://hbr.harvardbusiness.org/2004/06/redefining-competition-in-health-care/ar/1
"Health care competition, by contrast, has become zero sum: The system participants divide value instead of increasing it. In some cases, they may even erode value by creating unnecessary costs. Zero-sum competition in health care is manifested in several ways: First, it takes the form of cost shifting rather than fundamental cost reduction. Costs are shifted from the payer to the patient, from the health plan to the hospital, from the hospital to the physician, from the insured to the uninsured, and so on. Passing costs from one player to another, like a hot potato, creates no net value. "

I have always believed that healthcare competition does not work especially because there are parts of the market where there is demand but no real interest in providing service because of the return. But when you realize how the culture of healthcare impedes innovation; the bureacracy and unaligned incentives discourage change internally in healthcare institutions not just in the payor community, you see the need for breakthrough innovations to take market share. By the time technology is adopted in its entirety in the current structure, it is outdated and adds cost..
The structure of change and improvement is clearly a driver in this no-value equation.

Lessons from Defense.

The F-22 Model for Medicare
http://www.washingtonpost.com/wp-dyn/content/article/2009/07/21/AR2009072102811.html?wpisrc=newsletter

By Ruth MarcusWednesday, July 22, 2009
"If you're interested in how to get health-care costs under control, the case of the F-22 offers an instructive example"

Marcus provides a great example about what we are in for without a buffer for ongoing health policy.

From my experience, my state hasn't passed anything that resembles policy in over 20 years. But they have passed lots of political solutions.

The MedPac type option is the only thing that will allow healthcare to progress....
when we talk about "disruptive technologies" to begin to change the cost picture in healthcare, we are not talking about anything that exists in Congress! Pray for the MedPac (with some power) option to survive.

...And this is the AHA's take on the Public Option

From the AHA's position paper on Reform
The Public Plan Option
"National health insurance can be a useful medium in providing private coverage for those who
don’t receive it through their employer or qualify for public programs. The AHA has serious concerns, however, about establishing a new public plan that could exacerbate the underpayment American Hospital Association 2 of providers by paying rates at Medicare or Medicaid levels. The Medicare Payment Advisory Commission (MedPAC) projects that hospitals will have a negative 6.9 percent Medicare margin in 2009 – down from a positive 6.2 percent Medicare margin in 1999 – the lowest level in more than a decade. Hospitals also experience severe payment shortfalls when treating Medicaid patients; on a national level, the Medicaid payment shortfall amounted to $10.4 billion in 2007. These underpayments affect families as well. A recent AHA study by Milliman, Inc. found that annual health care spending for an average family of four is $1,788 higher than it would be if Medicare, Medicaid and private employers paid hospitals and physicians similar rates, with total provider reimbursement unchanged. The scope of such a plan should be limited to the uninsured, the selfemployed and small businesses.
Medicaid
The AHA supports expanding Medicaid eligibility with federal financing for the new populations
covered through expanding eligibility for children, parents and pregnant women up to 150
percent of the federal poverty level. It is important also to include provider payment protections as Medicaid expands. The AHA also supports a permanent process that, in times of economic
downturn, provides states temporary increases in the Federal Medical Assistance Percentage
(FMAP) to help support their Medicaid programs. Through maintenance of effort criteria, states
should be required to maintain their current levels of eligibility and enrollment, benefits and
provider payment rates. Any FMAP increase should apply to Disproportionate Share Hospital
(DSH) payments, with a corresponding increase in DSH allotments to accommodate the
enhanced federal match. These reforms are critical because states typically target their Medicaid programs in a search for savings through provider payment freezes or reductions, as well as benefits and eligibility changes, in times of economic turmoil. "

A Must Read on Public Option

The latest in Health Affairs/ Robert Wood Johnson Foundation's health policy briefs was released late last month. It provides the pros and cons of the public option in the health reform legislation making its way through Congress this month. http://www.healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_4.pdf.

It is one more piece of information as the Congress got slammed by its budgeteers on the cost of the entire reform package.

Public options are filtered for health leaders on their relationship with Medicaid and Medicare. Patients seem to have a different view. Most of us have had opportunity after opportunity to see bad policy created in the name of politics....and this is coming from a philosophical "single payor" person!

Health executives are in a position to frame this complicated information for their communities. Read on.

Do you know your net promoter score?

http://www.netpromoter.com/np/index.jsp

Pay cuts!

"House Financial Services Committee Chairman Barney Frank (D., Mass.) is working on legislation that could strengthen the government's ability both to monitor compensation and to curb incentives that threaten a company's viability or pose a systemic risk to the economy." WSJ 5-13-09.

Healthcare next? Its only a matter of time.....???

And by the way where do you think the $2 Trillion in cuts is coming from?

The role of the CEO is to tie the external to the internal

But many CEOs are drawn into the internal...the domain of costs and crisis and don't spend time in the external or bridging the two.

According to Harvard Business Reviews interview with AG Lafley Ceo of Proctor and Gamble http://hbr.harvardbusiness.org/2009/05/what-only-the-ceo-can-do/ar/1. Influenced greatly by Drucker he quotes Drucker “The CEO is the link between the Inside that is ‘the organization,’ and the Outside of society, economy, technology, markets, and customers. Inside there are only costs. Results are only on the outside.”

"But it has become clear to me that the CEO’s real and unique work draws on a uniquely external perspective that is inaccessible to the rest of the organization unless the CEO makes it accessible through choices and actions every day." P&G's CEO A. G. Lafley.

According to Lafley how does he focus on the external stakeholders: "drawn from Drucker’s observations:
1. Defining and interpreting the meaningful outside
2. Answering, time and again, the two-part question, What business are we in and what business are we not in?
3. Balancing sufficient yield in the present with necessary investment in the future
4. Shaping the values and standards of the organization"

P&Gs growth goals annually are very respectable if not daunting....given the stagnation of "customer value" in healthcare this may be the focus we are needing.

Lafley's trips are spent in customers homes and stores....How much real hands on time are healthcare CEOs spending in defining and interpreting the "meaningful outside"? Do you understand your meaningful outside.

Accessing Stimulus Funds

Everyone is speculating about what stimulus funds mean to them....can they use them to update systems, EMR/EHR.

John Glaser says get prepared now. http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/04APR2009/090414HHN_Online_Glaser&domain=HHNMAG
"Despite areas of uncertainty, hospital and health system leaders can take steps to prepare themselves. They can start by analyzing the financial incentives’ revenue potential and assessing the effort and expense to ensure they are using certified EHRs. They can also initiate two important conversations: first, with state officials about their intended approach to pursuing the regional and statewide health information exchange planning and implementation grants; and second, with local colleges regarding their interest in providing education for the information technology workforce that will be needed."

Emily Friedman:

"In the 1930s, the majority of hospital administrators were women; in 1940, 50 percent of members of what was then the American College of Hospital Administrators—now the American College of Healthcare Executives (ACHE)—were women. ....Now, of ACHE affiliates, only 12 percent of the women are CEOs

"Thesis 1: The future leadership pool should be similar to the overall population in terms of gender, racial and ethnic heritage, disability status and sexual orientation. This is neither a radical proposition nor an unattainable goal. As the data tell us, it is happening, anyway—to a point. That point, unfortunately, is in the CEO’s chair and the boardroom.

"Thesis 2: Despite fervent efforts by market-happy ideologues to ignore 25 years of evidence, health care is not a regular business, nor do pure competitive models apply to it. Yes, our organizations need to be operated in a businesslike manner, and competition on certain bases—quality of care, efficiency, community service—is healthy and promotes innovation. But the leaders of tomorrow will learn that the previous generation was wrong about some of the economic basics. Health insurers should not prosper by avoiding the sick; patients should not suffer because they are uninsured; the first reaction to a safety-net hospital in danger of closure should not be to try to pirate its nurses."

READ MORE of EMILY's 10 challenges facing next generation of leaders.
http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/04APR2009/090407HHN_Online_Friedman&domain=HHNMAG

Is this a conversation that needs to occur?

Geothermal Energy anybody?

Obama's stimulus package has a tax deduction of 30% of the cost of geothermal projects. If taxation isn't the draw, how about energy cost reduction!
Do you know what it is? Its using the earth's core temp (55 degrees) to moderate swings in above ground climate control (heating and cooling).
Interested? Read on.....
Geothermal energy is energy that is derived from the temperature of the earth. The earth absorbs 50 percent of all solar energy, and traps it as heat just below the frost line. Using a heat pump, this natural and renewable resource trapped below the earth's surface is transformed into a harnessable form of energy. This energy --geothermal energy-- provides buildings with a dependable, eco-friendly and economic heating and cooling system.

Geothermal heating and cooling technology has been given the best rating by the Environmental Protection Agency (EPA).
Geothermal energy is a renewable resource, and doesn't deplete non-renewable resources.
Geothermal energy does not produce any form of pollution. And, it doesn't contribute to the greenhouse effect.
Buildings that use geothermal energy use up to 40% less energy than other high-efficiency buildings.
Geothermal energy requires no outside sources of fuel to keep the power houses running.
According to a U.S. Energy Information Administration (EIA) report issued on Oct. 12, 2005, heating bills for all fuel types will cost Americans about one-third more during the 2005-2006 winter, on average. Projected rates for the Midwest are up to 61 percent higher than last year. With significantly rising energy costs, geothermal energy provides a cost-effective alternative for heating and cooling.

http://www.thefutureofsherman.com/energy_faq.php
Sherman Hospital plans to build one of the largest geothermal lakes in the world. Unlike other forms of geothermal technology, geothermal lakes rely on the heating and cooling properties of water.
The temperature at the bottom of the lake--a constant 55°F--will be the heating and cooling source for the hospital. The energy for the hospital will be harnessed by a lake loop-heat pump system under the water.

In addition to being recognized as one of the most environmentally-friendly hospitals in the country, Great River has saved more than $1 million annually over the cost of heating and cooling its old campus.

The United States first capitalized on geothermal energy in the early 1800s. The first commercial use? Three spring-fed baths in the city of Hot Springs, Arkansas, in 1830.
Geothermal technology is a dependable, proven technology with many uses around the world. Geothermal power plants are producing electricity in more than two countries, supplying about 60 million people with energy. In the U.S., geothermal technology supplies 4 million people in the Western U.S. and Hawaii with energy. More than 500 schools across the U.S. have adopted geothermal technology.

"these men's lives depend on good management and great leadership".

Harvard Business Review's description of a reality TV show about deep sea fishing (http://blogs.harvardbusiness.org/hbreditors/2009/04/on_crabs_and_leaders.html) decribed above goes on. "It makes sense to focus on the inherent drama of those specific moments of leadership. Those times when their decisions have immediate, and palpable repercussions." But what caught my eye, was that they did not say great management and good leadership. On the contrary, precarious times take good management and GREAT leadership. Are we focusing enough on leadership given what is on our plates to manage?

HBR points out how they do it:
"Strategy and execution. Every crab season starts with the captains deciding where to put their pots, and then adjusting that strategy as they get real-time data on their results, in the form of full or empty pots. By focusing efficient execution, keeping the fishing fast and safe, the crew can lay more pots and catch more crabs.


"Employee onboarding (literally). The captain must integrate rookie fishermen ("greenhorns") with the veterans, without much time for orientation or feedback. Usually, a deck boss handles this, but you will hear captains assessing their greenhorns and deftly putting them in positions to succeed, or in positions to see how they handle pressure situations.


"Competitive cooperation. Like many businesses, crab fishing is full of "frenemies." The captains work with and against captains of other crab boats to ensure their own success and also the success of the industry. Captains talk about where they've found good fishing grounds, and help each other in trouble. But the sharing only extends so far. In one episode a young captain gets too aggressive looking for help finding crabs and the other captains hasten to chastise him.

"Innovation. Ever try to fix a punctured hydraulic pump 30 feet above the deck of a boat, sitting on a slick, oil-soaked crane, rollicking in rough seas, during a snow squall?


"Morale. Obviously keeping the team's attitude up is one of the most important leadership functions in this environment. In many ways it's the core of the show. How do you keep men fishing for 20 or more hours straight in freezing weather, with 20-foot seas crashing over them, when the pots are coming up empty? "

Sound familiar? As they point out, Deadliest Catch is in its fifth season. Watch it!

Its right in front of our eyes...if we look!

Dr. Jay Parker, Brooklyn New Jersey, 32, gets it!
""Hello Health," the Brooklyn-based primary care practice that is fast becoming an emblem of modern medicine. A paperless, concierge practice that eschews the limitations of insurance-based medicine, Hello Health is popular and successful, largely because of the powerful and cost-effective communication tools it employs: Web-based social media."

Healthcare is lightyears away from utilizing technology and therefore lightyears away from meeting the increasing needs of most patients for real time access and information to manage their own healthcare.

( See article in Health Affairs http://content.healthaffairs.org/cgi/content/full/28/2/361) We are not talking big mainframe, CDs of images that have to be signed out and picked up, but real time use of social networking and online information, video and email.

Insurance needs to wake up to the benefits of paying for social networking communication between providers and patients and maybe even between providers....incentivize the effective and cost effective behaviors you want to see to save resources? Now theres a concept! Are you using social networking for your medical staff to communicate with each other and you?

How involved are your associates? Case Study: Boston employee forums

I have to admit to being very impressed not by the CEO's town forums as reported in the blog "running a hospital", since all of us have those events to keep people informed, but by the response from associates to problem solving during this economic crisis. It was really impressive and I think each hospital executive could find the same themes running through their organizations - unselfish, and practical. The blog: http://runningahospital.blogspot.com/2009/03/town-meetings-bidmc.html has comments from employees on how to cut costs and what they would forego to keep other people's jobs. It really harkens back to the HBR article that layoffs may not be good for the organization and leaders need to look deeper. The folks in Boston did that and looked directly to their employees for support. No matter what the outcome, the process seems excellent. Not naive, but good business.

So how involved are your associates? Do they have a hospital blog that is a vehicle for them to be part of the process? Do you have resources dedicated to it?

“We’re a high-volume, low-cost company,” Marcus Osborne, who works in health-care business development for the company, told NYT.

“And I would argue that mentality is sorely lacking in the health-care industry.”

So goes the announcement by Walmart of its plans to get into the Health IT business by targeting small doctor practices and keeping the costs very close to the incentive built into the Obama stimulus plan.

Full story WSJ: http://blogs.wsj.com/health/2009/03/11/wal-mart-to-sell-electronic-medical-records-to-doctors/

The comment that healthcare rarely commoditizes its products in a way to really go after the low cost niche seems to ring very true. How much is this a demand issue versus a supply issue? Even without incentive money out there this seems to be a need that goes largely ignored... and contributes to the impression of leadership voids in healthcare. Leaders demanding these products and setting the low cost parameters could come from healthcare...and as the dollars are conserved on the hospital side in Medicare to the tune of $139 billion, isn't it about time, we led the charge. Where are associations on the issue of cost of product? Do purchasing groups provide adequate leadership on this issue?

Not surprising

Half of nation's hospitals running losses
Many plan to cut services and staff as investment returns worsen and paying admissions decline, research shows.
By Lisa Girion http://www.latimes.com/business/la-fi-hospitals2-2009mar02,0,3182541.story

The LA times reports that over 50% of hospitals are running losses as investment income plummets and paying activity shrinks.

"Forty-four percent of hospitals have seen declines in surgeries, with hip procedures showing the steepest drop-off at 45%, according to another new survey. As a result, 47% of the hospitals surveyed expect to make staff cuts, and 69% plan to cancel or delay equipment purchases, according to the survey by Novation, a company that manages supplier contracts for hospitals".

Conventional wisdom of layoffs not holding up

Again in Harvard Business Review
http://hbr.harvardbusiness.org/2002/04/look-before-you-lay-off/ar/1
Look Before You Lay Off
by Darrell Rigby
"Downsizing in a downturn can do more harm than good. Layoffs, the conventional wisdom goes, are a necessary evil during economic downturns. The problem is, the conventional wisdom is wrong. Researchers at Bain & Company analyzed the layoffs at S&P 500 companies during the early stages of the current downturn (from August 2000 through August 2001) and found that even as layoff numbers reached record levels, most companies weren’t downsizing.
"...Rather, a small group of poorly performing companies accounted for the vast majority of firings, and their experience shows that reactive downsizing can backfire.During the study period, companies with few or no layoffs performed significantly better than those with large numbers of layoffs."

Hospitals across the country are announcing layoffs to preserve cash/cut costs. Good idea? Are these jobs that begged to be eliminated earlier but were a distraction or are these jobs that will "just come back" in six months. Are boards pressuring to lay people off? Do you think it will make a difference?

How big is too big?

In this month's Harvard Business Review, Duncan Watts asks the question: "Too big to fail, or too big to exist?" "Having studied the dynamics of cascades in complex systems, I suspect that the most damaging ones are impossible to anticipate with any confidence. The solution may therefore be to make the system less complex to start with, in part by limiting how big companies are allowed to become."

He refers to banks and the financial services industry obviously, but brings us back to utility meltdowns that cascaded across several states affecting millions of people.

Is it time to apply this thinking to healthcare? How big is too big? When do economies of scale matter and at what risk? Is there a too big healthcare system? And what are the consequences of it failing. Is size actually protecting and stabilizing healthcare?

While this might seem a stretch, todays headlines in Wall Street Journal, New York Times and Modern Healthcare all refer to the steep drop off in stock prices for Medicare Advantage Insurers. When are health consumers at risk of organizations too big to exist?

29% of the GDP is either healthcare or deficit!

Enough said!

Dominos: pizza tracker!

I ordered a pizza on line last night. (Okay its not healthy but thats not the point.) I typed in my zip code, covered my virtual pizza with toppings and paid with a credit card (but it could have been cash). That is where the amazing thing happened. All the mystery went out of my pizza preparation and transport...The Tracker popped up on the screen. It turned colors as it went from identifying a location and transmitting the order, to preparation, to the oven, to the delivery vehicle in route to my front door....all on my tracker on my computer! I never had to worry that they lost my order, it was sitting somewhere not making its way onto the delivery truck. All I had to do was call my kids and say, I think its on its way, wash your hands as the light on the delivery bar went from red to blue!

Couldn't we give our patients and outpatient customers the same piece of mind that their orders are being scheduled and that we know where in the queu they are? Shouldn't we build confidence and reduce anxiety as part of our process? Can't we adopt the Pizza Tracker!

I have to give DHL, Fedex, UPS and others a nod for a similar experience. Scheduling and tracking doesn't seem to be rocket science anymore.

Don't get me wrong, I get those nice little digital reminders on my phone that I have an appointment coming up. But this seemed to share the process in a way that was, shall we say, transparent! After waiting from 6am until 7pm for agreement on my own discharge orders, I could have used the pizza tracker!

Obama: health care reform = health cost reduction!

In his speech to a joint session of Congress Tuesday night, President Obama, as a prelude to saying health reform can't wait, sited health-care costs as the biggest problem. Cost are “one of the major reasons why small businesses close their doors and corporations ship jobs overseas” and “one of the largest and fastest-growing parts of our budget.”

In his budget submitted to Congress yesterday, Obama asked for a health fund of over $600 billion to fund his new programs, but staff said that did not cover the cost of the full program in the ten year budget. Cost reduction and "efficiencies" will be needed to fund the program.

Universally, institutions appear to be in the process currently of ratcheting down costs in an effort to stabilize balance sheets and bottomlines. Will there need to be an end to competition as the solution and a return to 60s style health planning to meet these goals? How are Boards being prepared to think differently in this environment?

Spending on hospital care to double in 10 years to $1.4 trillion and consume 20.3% of GDP

In an article posted February 24, 2009 - 5:59 am EDT, "Growth in healthcare spending expected to slow: CMS" By Jennifer Lubell in Modern Healthcare, http://www.modernhealthcare.com/article/20090224/REG/302249977

CMS estimates that "the growth in national healthcare spending is projected to slow in 2009...The study... estimates that healthcare spending will have reached $2.4 trillion by 2008.

"In other trends, growth in spending on hospital care is expected to slow to 5.7% in 2009 from 7.2% in 2008, as a result of slower private spending growth for hospital care. Over the next 10 years, spending on hospital care is expected to reach nearly $1.4 trillion, up from a projected $746.4 billion in 2008.

"Growth in spending among public payers is expected to accelerate from 6.4% in 2007, ... driven largely by faster growth in Medicaid enrollment and spending. By comparison, private health spending growth is expected to fall to a 15-year low of 3.9% in 2009, The CMS predicts the growth rate in national health spending will rise again in 2011 as economic conditions improve."

Does this mean greater pressure for Medicaid to pay its full cost+ in all states? In many states, Illinois being one that I am familiar with, Medicaid seriously underpays all providers other than the "high DSH" hospitals that are completely dependent on Medicaid for their survival. Private funding makes up the bottomline for these providers. With shrinking private funding will hospitals ramp up pressure to get Medicaid rates closer to Medicare in anticipation of a single payor? Can your community afford 20.3% of the GDP in health? Or are you in a community where that is already the case.

See full article in Modern Healthcare under quick references below.

If Your Type A personality doesn't meditate...

Any break in a stress cycle every 90 minutes for 1-2 minutes is beneficial! So for non-meditation types, a play list of Rock is attached under wellness.....Just move out of your zone every 90 minutes....called Recovery time! Your body and mind will appreciate the effort and discipline. If that playlist doesn't work for you, create your own - its free! And will make teenagers in your life sit up and respect you more! Enjoy!

Meditation: Take a stress-reduction break wherever you are

STRESS KILLS! Even for those of you who are on the extremes of perfect emotional intelligence, healthcare leadership comes with stress and many female leaders don't adequately attend to it for themselves. We are adding a blog section on wellness links to make it as easy as saying Om to begin stress reduction today. Also attached today is an article on meditation from the Mayo Clinic. This is by far not the most radical but its a start! 20 minutes of concentrated quiet finding your center is not impossible.

"Meditation — Learn quick and easy ways to meditate, no matter where you are. "
http://www.mayoclinic.com/health/meditation/HQ01070

Even better would be a few Yoga or tai chi moves in your office or out on the front lawn for all the healthcare community to see your example! Too Much for now, okay, maybe in your office and next year we will see you leading the charge.

For women, the hormone balance provided by both meditation and yoga are increasingly mentioned in the popular media and among female physicians.

David Brailer suggests Obama jump start IT to make up for the lag

http://healthaffairs.org/blog/2009/01/14/complete-the-work-on-health-information-technology/

"President-elect Obama recently placed health IT among the critical infrastructures that are essential in the 21st century. He rightly recognizes that health care is one of our few remaining economic sectors where IT has not taken root. His health reform plan relies upon health IT to reduce costs and improve efficiencies. He has pledged $50 billion to bring health information tools into widespread use (which is $49,950,000 more than President Bush gave me to spend).
Now that we are well into the transition, reasonable questions to ask are, What should the President-elect do to get health IT into widespread use? What should he do differently from President Bush? What should he not do?

A Health IT Agenda For President Obama
First and foremost, President-elect Obama needs to address the growing chasm between the physicians and hospitals that have electronic records and those that do not. Most large and urban hospitals as well as larger physician practices are far along in using EHRs. Rural hospitals, nursing homes, and small physician practices lag far behind. They face many barriers, but foremost among them is the lack of capital to purchase and implement information tools. We were reluctant to offer government incentives for electronic records, preferring market forces to drive adoption as far as possible. Sales pipelines and hospital and physician budgets show that EHR purchases have slowed, indicating that the market wave has gone as far as it can."

How do you think government incentives should work to assure real progress? How much time and money is your organization devoting to IT? How much time and attention are you personally devoting to the stimulus bill?

Interesting commentary on SEIU's Hospital Corporate Campaigns in Hospitals with High Employee Satisfaction

http://runningahospital.blogspot.com/2009/02/innocent-until-seiu-says-otherwise.html. This article highlights the havoc that the card-check legislation could bring to hospitals that have stable and professional workforces. It seems that while most would agree that it is often difficult to create policies that protect each and every associate, the current track record of SEIU is more about protecting SEIUs growing political power base.

http://www.chausa.org/Pub/MainNav/News/CHW/Archive/2008/1201/Articles/w081201d.htm In this Catholic Health World article (not well disseminated outside of Catholic Healthcare), Deborah Proctor outlines their thoughtful approach to protecting workers rights under the law by standing up to the corporate campaign against St. Joseph in Orange.

It might be interesting to know if there are proactive approaches being used with Democrats to dissuade them on the card check issue. The manufacturing and financial services industries do not appear to have the credibility to carry this water.

Is bad debt becoming your charity care?

According to the Kaiser Family Foundation, every one percentage point increase in the unemployment rate generates 1.1 million more uninsured persons and adds 1 million more Medicaid and State Children's Health Insurance Program beneficiaries.

As uninsured and underinsured numbers grow, should the CHA relook at its charity care policy?

WSJ.com - Report Sheds New Light on Nonprofit Hospitals

WSJ.com - Report Sheds New Light on Nonprofit Hospitals* This article will be available to non-subscribers of the Online Journal for up to seven days after it is e-mailed.

How do you keep up?

Not your spirits, although in this economy that would be a legitimate question, but how do you stay on top of all the information sources? What are your top priorities? New information, news, who is where? What topics are a must? Politics, Reimbursement, Cost, New Technology?

Is "bonus" a dirty word? Is there real performance in "pay for performance?

"$18 billion in bonus pay" screech the headlines. And for what?

The key question is not about how much but for what benefit, to the firm, and now with the global crisis, the US economy and even the world stage.

As healthcare executives, under the spotlight regarding tax-exempt status, (even if it has diminished in the glare of wall street issues), incentives and total compensation are a huge issue. Does that mean they are wrong? The real question is "are you getting what you are paying for?", "could you have gotten it anyway without the incentive?" and "can you explain it to the average American in 8 to 10 words across the headline of your local paper?". That is the real issue. Are the incentives crystal clear (transparent) to all involved as to what they are paying for.

It seems that this is a unique time to rethink this issue. We need greater leadership than ever, greater acccountability, productivity, creativity....are we paying for measurable progress that the community understands.

Can you see the headline?: CEO Jane Doe received 32% of salary for decreasing mortality at X by 50% in 9 high volume procedures. (19 words!) Try "CEO gets huge payout for exceptional quality report! (8 words - is more like what the paper will give you). Or "System rewards leaders for 15% market share gain". "Zero preventable accidents scores bonus for leadership"! "Hard choices provide security for those left behind."

Many companies are eliminating raises this year. Oil Companies, major players. I bet those employees would be willing to look at pay for performance.

How are you looking at bonuses/incentives differently?

Recession Advice: Stick to your values

"All of this stress means an increase in irritable, angry, demanding, stressed out patrons who are rubbing up against your irritable, angry, tired, stressed out staff."

From the local librarian, remember your associates!

1. "make sure staff feel appreciated
2. encourage open communication
3. training (almost any it seems)
4. provide clear goals and expectations
5. encouraging a sense of team
6. empowering staff
7. be flexible with time and schedules"

http://librarianbyday.wordpress.com/2009/01/09/library-usage-will-go-up-during-a-recession-management-are-you-really-prepared/

Recession hits healthcare

"It's a myth to think hospitals are recession-resistant," says Sheryl Skolnick, an analyst with CRT Capital Holdings. "During the 2001-2002 recession there was the lowest demand for hospital services ever.

A large consumer survey conducted in February by Deloitte & Touche's Deloitte Center for Health Solutions found that only 11% of consumers feel they can handle upcoming medical bills.

http: //www.businessweek.com/technology/content/mar2008/tc20080324_828167.htm

Welcome!

Having served in a number of institutions and watching busy CEOs and execs struggle to get the latest news and better yet, know what their colleagues are thinking about it, it seemed that the internet held a great opportunity. The Blog reserves the right to limit submissions overtime if the information based on comments is not particularly useful to the readership.This is meant to be your blog - more than data shared it is meant to stimulate thinking and reaction to the serious issues and the not so serious issues affecting the healthcare leader.