Health Affairs November issue tackles the biggest issue in health care today..the real challenge, obscured by the silly discussion last summer of death panels. And what is this issue? Value based insurance or insurance paying only for the most effective care. That doesn't mean that other care is not available - it is only available at a price because while it might be the right choice for you to make, it is not proven and is a personal choice.
Of all the choices that we currently make as a society that are so counterintuitive to the science - not paying for prevention, not having universal coverage for children, not paying for all primary care- this makes the most sense. As a society, we put our scarce resources where we know they work and we invest in science and let individuals pay for care that is not justified by science but in a miracle situation might help them.
I might pay for certain things...or I might ask for the real deal and save myself the suffering.
Interesting questions this will raise about our approach to science.
Monday, December 13, 2010
My doctor visit
An hour and a half into the visit, my doctor repeated for the fifth time "you can blame Obama for this". She was referring to their new Epic system that was taking hours to enter new patient history information. I was amazed at what a speedy typist my doctor was! But even that didn't speed things up. By the eighth "Obama" and "they did this to get several thousand dollars", I was worn out. My physical exam had yet to be started and I was feeling increasing nervous about what would have gone on my chart if they hadn't blocked the "other" field.
I did get out of there with a number of nicely typed prescriptions and the confidence that this system was here to stay...but I had to wonder about the design of the system - after doing research I applaud the blocking of the "other" option...(I digress, but over 30% of my sample in a recent study at a leading academic medical center matched on "other or unknown"...they were an early adoptor!) Are we investing in permanent systems that are slow and not intuitive for how physicians work. Did my extra time with the doctor go into typing and even less communication? Will this work with a hand-held device like an ipad that you can easily flip the pages with a finger to find your information?. My medical home just became a victim of the computer that has invaded all interactions in my own home. I am a huge supporter but I wonder....
I did get out of there with a number of nicely typed prescriptions and the confidence that this system was here to stay...but I had to wonder about the design of the system - after doing research I applaud the blocking of the "other" option...(I digress, but over 30% of my sample in a recent study at a leading academic medical center matched on "other or unknown"...they were an early adoptor!) Are we investing in permanent systems that are slow and not intuitive for how physicians work. Did my extra time with the doctor go into typing and even less communication? Will this work with a hand-held device like an ipad that you can easily flip the pages with a finger to find your information?. My medical home just became a victim of the computer that has invaded all interactions in my own home. I am a huge supporter but I wonder....
What next
Today we learned that one of the challenges for individual mandates in the health reform bill is deemed unconstitutional. While the challenges continue, those of us on the provider side need to move forward - knowing that increasingly, less money is coming into the provider networks and more is asked of the providers. Costs will skyrocket for business this year while healthcare organizations will not see the increase. What does that mean for most organizations?
In general providers need to make the daring switch to more and more managed care while hoping that their cash cow subspecialty services continue to pay off in the short term. "Its the transition stupid" to steal a line from the political folks...and to steal a really bad line (apologies to those who are still sensitive), "size does matter" in this issue! For those stand alone small community hospitals, all the challenges do is delay your dealing with the inevitability that your size does matter and that you can't invest fast enough to grow outpatient. Build it and they will come is not a strategy that will do anything in this environment...but use capital.
So as you read the starts and stops in health reform...know that there are several things you can hang your hat on.
1. Business will not pay more, so the focus on cost cutting will be severe.
2. Cost cutting will start with high coverage plans
3. The hospital will indeed become less lucrative over time and the outpatient network to support inpatient volume is sizable.
4. Readmissions will cost you dearly. Focus like a laser on them and how to back fill them.
5. When you realize you can't start looking at capacity!
And have a happy holiday season...January may be worse!
In general providers need to make the daring switch to more and more managed care while hoping that their cash cow subspecialty services continue to pay off in the short term. "Its the transition stupid" to steal a line from the political folks...and to steal a really bad line (apologies to those who are still sensitive), "size does matter" in this issue! For those stand alone small community hospitals, all the challenges do is delay your dealing with the inevitability that your size does matter and that you can't invest fast enough to grow outpatient. Build it and they will come is not a strategy that will do anything in this environment...but use capital.
So as you read the starts and stops in health reform...know that there are several things you can hang your hat on.
1. Business will not pay more, so the focus on cost cutting will be severe.
2. Cost cutting will start with high coverage plans
3. The hospital will indeed become less lucrative over time and the outpatient network to support inpatient volume is sizable.
4. Readmissions will cost you dearly. Focus like a laser on them and how to back fill them.
5. When you realize you can't start looking at capacity!
And have a happy holiday season...January may be worse!
Thursday, November 18, 2010
$48 million
Premiums are going up, government is criticized for health spending, and $48 million dollars went to three people in total compensation. Those fortunate few were the tireless executives at some of the nations top health insurance companies. ($74 Million went to the top 7!) With average per capita health spending at $8k that is the equivalent of 6000 people (including children) that could have received excellent coverage without affecting the profits of those companies. Call me socialist, but that is the tip of the iceberg! That is only 3 executives!
Now realize that our health dollars also pay value and dividends into retirement plans for shareholders and you see the benefit of the insurance industry as a money machine not as a delivery system. Nothing wrong with capitalism again, unless your goals are access to affordable care and improved health status of our population. (Health status impacts productivity, national defense and social security (disability).) Its amazing how those socialist goals jive with capitalism!
So this is a bit like paying the generals in our army and air force huge salaries to privatize the military, because the government doesn't run things well. And then we all buy stock in it to fund our retirement programs. And then they sell off our national security goals to make sure the stockholder value doesn't go down....maybe by only invading oil rich countries....(oh yeah we already did that!) and then....
I think I will stick with the good old socialism we used to call the common good and continue to advocate for the public option.
I always thought I was a capitalist as the CEO of an organization. But I am beginning to like this socialist thing! Thanks to Fox and friends for pointing it out!
Now realize that our health dollars also pay value and dividends into retirement plans for shareholders and you see the benefit of the insurance industry as a money machine not as a delivery system. Nothing wrong with capitalism again, unless your goals are access to affordable care and improved health status of our population. (Health status impacts productivity, national defense and social security (disability).) Its amazing how those socialist goals jive with capitalism!
So this is a bit like paying the generals in our army and air force huge salaries to privatize the military, because the government doesn't run things well. And then we all buy stock in it to fund our retirement programs. And then they sell off our national security goals to make sure the stockholder value doesn't go down....maybe by only invading oil rich countries....(oh yeah we already did that!) and then....
I think I will stick with the good old socialism we used to call the common good and continue to advocate for the public option.
I always thought I was a capitalist as the CEO of an organization. But I am beginning to like this socialist thing! Thanks to Fox and friends for pointing it out!
Friday, October 1, 2010
Let the games begin
As I sit in the University of Michigan hospital and watch the amazing delivery of complex care to a diverse group of individuals, its hard to see what's wrong with the system. Then I started reading "Insurance Companies drop Children Only Policies" to avoid the restriction on limiting insurance for preexisting conditions and it hits you in the face....the system is doing what it always does...gaming! "Creaming, Gaming, Dumping" . No matter what you call it, the distortions and hurdles continue to emerge. Take one step forward, you get two steps back. And of course, how do you think profitable organizations work? They are nimble, respond to the new environment, opportunitistic. Its what we love about capitalism as long as we are an investor.
But what about when you are the recipient, not of a behavior driven disease (which we love to hate) but of an out of nowhere cancer at age 8? What then do we think about the creativity of gaming as opposed to using that creativity to try to cover and care for all (or at least more) people.
So right now as I watch clinicians do their thing for complex 90 year olds and tired 8 year olds, I wonder why we are so focused on rolling back health reform . Why are we not studying the "games" and policies of the private sector this year and amending reform to close the loopholes. Why are we not angry that instead of working to meet the goals of the program each organization is in it for themselves. Government planning is not a bad thing.. think roads, schools, zoning, military deployment!
Let the games begin and make sure the gamers know we are watching!
But what about when you are the recipient, not of a behavior driven disease (which we love to hate) but of an out of nowhere cancer at age 8? What then do we think about the creativity of gaming as opposed to using that creativity to try to cover and care for all (or at least more) people.
So right now as I watch clinicians do their thing for complex 90 year olds and tired 8 year olds, I wonder why we are so focused on rolling back health reform . Why are we not studying the "games" and policies of the private sector this year and amending reform to close the loopholes. Why are we not angry that instead of working to meet the goals of the program each organization is in it for themselves. Government planning is not a bad thing.. think roads, schools, zoning, military deployment!
Let the games begin and make sure the gamers know we are watching!
Monday, September 27, 2010
Too big to fail? Too small to survive?
It seems that it takes generations for hospitals to close. Predictions are made that beds are redundant and that hospital can't last and yet many hang on, a skeleton of their former selves, for years. Most experts believe that may be a thing of the past. A rapid period of acquisition, merger and closures may be the reality as both operating and capital dollars are stretched and consolidated in large integrated organizations.
As with the banking industry, the big got bigger and stronger (with the exception of the foreclosure bubble) and the small players couldn't survive the rapid need to accumulate capital and to compete broadly across service lines. The big became too big to fail and the small banks began failing at an accelerated rate.
In healthcare, too big to fail may mean that they have the tools to survive, the systems, the ability to consolidate services in fewer facilities, the political clout and the expertise. They may be able to make changes that survive in a more transparent era because of the demands of internal transparency.
Boards need to look seriously at objective data about the costs and timing of transforming the organization to integrated models that can compete. For inner city and rural communities these questions will be very difficult. Can you maintain the quality and cost competitiveness to capture a sustainable market? What are the alternatives for your community? What services could be consolidated with other partners in the community? Are their "e-health" opportunities?
As a small independent hospital, if you are planning on going it alone, read up on the banking industry! You may want to rethink the strategy!
As with the banking industry, the big got bigger and stronger (with the exception of the foreclosure bubble) and the small players couldn't survive the rapid need to accumulate capital and to compete broadly across service lines. The big became too big to fail and the small banks began failing at an accelerated rate.
In healthcare, too big to fail may mean that they have the tools to survive, the systems, the ability to consolidate services in fewer facilities, the political clout and the expertise. They may be able to make changes that survive in a more transparent era because of the demands of internal transparency.
Boards need to look seriously at objective data about the costs and timing of transforming the organization to integrated models that can compete. For inner city and rural communities these questions will be very difficult. Can you maintain the quality and cost competitiveness to capture a sustainable market? What are the alternatives for your community? What services could be consolidated with other partners in the community? Are their "e-health" opportunities?
As a small independent hospital, if you are planning on going it alone, read up on the banking industry! You may want to rethink the strategy!
Friday, September 24, 2010
Accountable Care Organizations ... can you afford not to?
If you were to follow the advice of others on the 5 things you need to do to get your ACO off the ground, you will fast see an expense-side model ...expand primary physicians, hire mid-level practitioners, invest in EMR and utilization management software, marketing costs, facility costs, and "culture change"! You would be right to be a bit dismayed. So do you march forward loading on expenses? How do you get the structure in place without the expense?
First, there is some analysis to be done, including:
1. Look at the size of the organization and the impact of a more effective primary care culture on the existing resources. Gauge the unused capacity of the existing system as you transform.
2. Put some of that potential unused capacity into the analysis. If you can use it for dual purpose (physicians and facilities) it might help the transition; on the other hand that unused capacity in the short term could lose per unit income value as you move to ambulatory. In other word, you could lose your shirt!
3. If your transformation will not sustain the organization long term, the strategy is partnering and best use.
4. If the transformation is sustainable, it is time to be competitive on the primary care side. What are some options. Expand midlevel practitioners into existing practices and focus on educating existing primary care physicians on medical home best practices.
5.When broadening your primary care base, think structure before bodies. A true medical home model has fewer patients per doctor, more time per patient, electronic communication between patient and doctor and all sorts of structures to keep utilization of expensive services down.
Can you afford it? "It depends on what the meaning of 'it' is?"
The true meaning may lie in the risk on the medical loss ratio? It doesn't matter your cost as long as you are making a margin. This is a time when no margin no mission is very easy to see!
First, there is some analysis to be done, including:
1. Look at the size of the organization and the impact of a more effective primary care culture on the existing resources. Gauge the unused capacity of the existing system as you transform.
2. Put some of that potential unused capacity into the analysis. If you can use it for dual purpose (physicians and facilities) it might help the transition; on the other hand that unused capacity in the short term could lose per unit income value as you move to ambulatory. In other word, you could lose your shirt!
3. If your transformation will not sustain the organization long term, the strategy is partnering and best use.
4. If the transformation is sustainable, it is time to be competitive on the primary care side. What are some options. Expand midlevel practitioners into existing practices and focus on educating existing primary care physicians on medical home best practices.
5.When broadening your primary care base, think structure before bodies. A true medical home model has fewer patients per doctor, more time per patient, electronic communication between patient and doctor and all sorts of structures to keep utilization of expensive services down.
Can you afford it? "It depends on what the meaning of 'it' is?"
The true meaning may lie in the risk on the medical loss ratio? It doesn't matter your cost as long as you are making a margin. This is a time when no margin no mission is very easy to see!
Tuesday, September 21, 2010
Primary care without exams?
No physical exams! The following article comments on the fading focus on physical exams by many primary doctors in lieu of just ordering expensive tests. Just as the effort to move to evidence based medicine has traction, we seem to be losing sight of the goal. (See report attached. http://www.npr.org/templates/story/story.php?storyId=129931999).
The trend is evident to both patients and specialists and has raised some red flags. The specialty referral system for instance at Cook County requires community physicians to document what data they have that prompts the need for a referral. However, there is little communication between private specialists and primary care doctors that they are referring patients inappropriately without a proper work-up because of both culture and economic concerns tied to referrals.
Patients should demand complete examinations before being exposed to dangerous testing. CT scanning exposes patients to significant radiation and may be unnecessary for many patients. My guess is that the number of negative findings are high.
Primary care requires time for thorough physical exams and attentive listening. Speeding primary care patients through the system to a more expensive and less wholistic testing system is a old mindset that healthsystems should pay close attention to.
The trend is evident to both patients and specialists and has raised some red flags. The specialty referral system for instance at Cook County requires community physicians to document what data they have that prompts the need for a referral. However, there is little communication between private specialists and primary care doctors that they are referring patients inappropriately without a proper work-up because of both culture and economic concerns tied to referrals.
Patients should demand complete examinations before being exposed to dangerous testing. CT scanning exposes patients to significant radiation and may be unnecessary for many patients. My guess is that the number of negative findings are high.
Primary care requires time for thorough physical exams and attentive listening. Speeding primary care patients through the system to a more expensive and less wholistic testing system is a old mindset that healthsystems should pay close attention to.
Tuesday, September 14, 2010
Ten mistakes leaders don't recognize in themselves
You are good. You get results. You are smart enough to know where you want the organization to go. Your Board was thrilled when you were hired! So what could possibly be wrong with this scenario.
Possibly nothing but unfortunately new managers and experienced managers fall into traps, patterns and activities that impede their effectiveness and may jeopardize their jobs. And they rarely see it in themselves, causing stress and frustration for themselves and their organizations.
My top ten observations are the following:
1. Losing track of the vision and big picture - managers that begin to focus on anecdotal evidence when quantitative evidence identifies a problem are on a slippery slope. Addressing a piece of data or a declining metric with a reflective "what processes are driving this" and "what do we need to correct in the process" will keep you out of the weeds and on course. Seeing each metric as a need for blame and explanation loses the focus. The turnover of several managers that drives the rate upward might be addressed as an issue with screening or it might be a problem with the job description. Focusing on "the candidate wasn't the right fit after all" or that your VPs "are bad at interviewing" will not resolve a thing.
2. Believing that your unique program idea from several years back is still working. Everyone has the new idea to really move the organization forward and we are so proud of those accomplishments. However, as time goes on, and if your tenure is long, you will need to look at your former bright ideas with some distance and humility. They may be the new opportunity to cut back. They may not be sustainable. A leader has to be as open-minded and attentive to his/her tired ideas as to the next bright ones.
3. Believing that certain problems are fixed once and for all. There is nothing so challenging as fixing a process. It is hard detailed work and needs to be hardwired. There is nothing quite as embarrassing as claiming "Mission Accomplished" only to find that the process has unravelled again. Ongoing monitoring and evaluation of process improvements needs to be hardwired into the management team.
4. Seeing your staff as increasingly obstructionist, lazy or intellectually limited. Times are stressful and you are working so hard to bring your team along on the latest challenge. You cajole, you threaten (carrot and stick) but you are walking away from meetings unable to contain your frustration. You just think that they don't know how great they have it, and "why aren't they going along". Your superiority complex is showing through. And they see it. And they don't think that the cajoling and lectures are helping. The trick is to step back, articulate the problem, the drop dead dates, the critical success factors and give it over to them. Be as clear as you can on the must-haves and leave the rest to them. If they can understand what progress means, they will get it done.
5. Seeing your board as increasingly inquisitive, overarching and demanding. This one is scary, because you may be the rare person who is right, but generally if you have a problem with your board and how they are reacting, they have a bigger problem with you. It is the CEO's job to deal with the board, not vice versa. The CEO must tee up the questions that the organization needs addressed. That means straightforwardly articulating problems, challenges, what has worked and what has not. Co-opting the Board as your partner is essential to your longevity.
6. Micromanaging the process to achieve an outcome at all costs. Similarly to the number 4 above, this represents a CEOs inability to let go of the solution and letting the team get the work done. But even more so, its the manager who pushes the process or idea beyond where it seems feasible, and creates an environment where no one will tell you when its time to turn back. Think BP. Think surgical mistakes. Think capital projects gone awry.
7. Losing directness with staff in order to engage them more. Just tell them what you want them to do. "I need this". "I am being held accountable for that". You will be held accountable for this performance, this project, this outcome. I need it by Friday. You can be perfectly friendly and still be clear.
8. Lack of follow-up. When an issue comes up, followup on it or it will be very clear to all that its not important. If you don't care to ask, they won't care to do it. The easiest way to follow-up is for weekly updates. Discipline is the first thing that goes with a management team over time.
9. Lack of accountability management and relaxed controls. How you develop an accountability structure to hold others accountable (beyond what they themselves report, is key. It can't be the last thing on the agenda. It has to be the first. Goals, timetables and rewards need to be crystal clear and fair. CEOs who have found a discrepancy in finance or another area often cite that they "didn't see it coming, they had worked with the person for a long time, how were they to know". Controls, audits, checklists, mandatory vacations are key to keep everyone out of trouble. This leads to the last.
10. "The Rules don't apply to me". This can land you in jail! But in the least case, it creates an arrogance that is intolerable for the organization. It could be the hypocrisy in not following work rules that others need to follow. Or it could be more dangerous, in deciding that budgets and timetables aren't working, so we just ignore them. Policies that the board has set aren't working, so instead of revisiting them with the Board, you just do it your way. This is a slippery slope, and one that no one admits to, but people often fall prey to. Not keeping good expense records. Not following hiring policy. These are the things that make you look quite silly when uncovered and lose respect from your staff while its going on.
I could add a last one entitled "staying too long". However, if you pay attention to the other pitfalls of senior management, you might be able to stick around for a very long time. In general though, as Mayor Daley said in announcing his decision to not seek reelection "Its Time. Its time for me and the city." There does become a time when it is best for all, in terms of energy and enthusiasm, to move on. So make that choice yourself by paying attention to the top ten. And seek support from outside the organization to keep perspective on the big (and small issues).
Possibly nothing but unfortunately new managers and experienced managers fall into traps, patterns and activities that impede their effectiveness and may jeopardize their jobs. And they rarely see it in themselves, causing stress and frustration for themselves and their organizations.
My top ten observations are the following:
1. Losing track of the vision and big picture - managers that begin to focus on anecdotal evidence when quantitative evidence identifies a problem are on a slippery slope. Addressing a piece of data or a declining metric with a reflective "what processes are driving this" and "what do we need to correct in the process" will keep you out of the weeds and on course. Seeing each metric as a need for blame and explanation loses the focus. The turnover of several managers that drives the rate upward might be addressed as an issue with screening or it might be a problem with the job description. Focusing on "the candidate wasn't the right fit after all" or that your VPs "are bad at interviewing" will not resolve a thing.
2. Believing that your unique program idea from several years back is still working. Everyone has the new idea to really move the organization forward and we are so proud of those accomplishments. However, as time goes on, and if your tenure is long, you will need to look at your former bright ideas with some distance and humility. They may be the new opportunity to cut back. They may not be sustainable. A leader has to be as open-minded and attentive to his/her tired ideas as to the next bright ones.
3. Believing that certain problems are fixed once and for all. There is nothing so challenging as fixing a process. It is hard detailed work and needs to be hardwired. There is nothing quite as embarrassing as claiming "Mission Accomplished" only to find that the process has unravelled again. Ongoing monitoring and evaluation of process improvements needs to be hardwired into the management team.
4. Seeing your staff as increasingly obstructionist, lazy or intellectually limited. Times are stressful and you are working so hard to bring your team along on the latest challenge. You cajole, you threaten (carrot and stick) but you are walking away from meetings unable to contain your frustration. You just think that they don't know how great they have it, and "why aren't they going along". Your superiority complex is showing through. And they see it. And they don't think that the cajoling and lectures are helping. The trick is to step back, articulate the problem, the drop dead dates, the critical success factors and give it over to them. Be as clear as you can on the must-haves and leave the rest to them. If they can understand what progress means, they will get it done.
5. Seeing your board as increasingly inquisitive, overarching and demanding. This one is scary, because you may be the rare person who is right, but generally if you have a problem with your board and how they are reacting, they have a bigger problem with you. It is the CEO's job to deal with the board, not vice versa. The CEO must tee up the questions that the organization needs addressed. That means straightforwardly articulating problems, challenges, what has worked and what has not. Co-opting the Board as your partner is essential to your longevity.
6. Micromanaging the process to achieve an outcome at all costs. Similarly to the number 4 above, this represents a CEOs inability to let go of the solution and letting the team get the work done. But even more so, its the manager who pushes the process or idea beyond where it seems feasible, and creates an environment where no one will tell you when its time to turn back. Think BP. Think surgical mistakes. Think capital projects gone awry.
7. Losing directness with staff in order to engage them more. Just tell them what you want them to do. "I need this". "I am being held accountable for that". You will be held accountable for this performance, this project, this outcome. I need it by Friday. You can be perfectly friendly and still be clear.
8. Lack of follow-up. When an issue comes up, followup on it or it will be very clear to all that its not important. If you don't care to ask, they won't care to do it. The easiest way to follow-up is for weekly updates. Discipline is the first thing that goes with a management team over time.
9. Lack of accountability management and relaxed controls. How you develop an accountability structure to hold others accountable (beyond what they themselves report, is key. It can't be the last thing on the agenda. It has to be the first. Goals, timetables and rewards need to be crystal clear and fair. CEOs who have found a discrepancy in finance or another area often cite that they "didn't see it coming, they had worked with the person for a long time, how were they to know". Controls, audits, checklists, mandatory vacations are key to keep everyone out of trouble. This leads to the last.
10. "The Rules don't apply to me". This can land you in jail! But in the least case, it creates an arrogance that is intolerable for the organization. It could be the hypocrisy in not following work rules that others need to follow. Or it could be more dangerous, in deciding that budgets and timetables aren't working, so we just ignore them. Policies that the board has set aren't working, so instead of revisiting them with the Board, you just do it your way. This is a slippery slope, and one that no one admits to, but people often fall prey to. Not keeping good expense records. Not following hiring policy. These are the things that make you look quite silly when uncovered and lose respect from your staff while its going on.
I could add a last one entitled "staying too long". However, if you pay attention to the other pitfalls of senior management, you might be able to stick around for a very long time. In general though, as Mayor Daley said in announcing his decision to not seek reelection "Its Time. Its time for me and the city." There does become a time when it is best for all, in terms of energy and enthusiasm, to move on. So make that choice yourself by paying attention to the top ten. And seek support from outside the organization to keep perspective on the big (and small issues).
Sunday, September 12, 2010
The operations storyboard
Its election season and the messaging gets shorter and shorter. And focused on the least complex issues and never really going to the heart of the matter. Frustration has set in among voters and they are happy to vote in the most outrageous person based on the clarity of the message. And of course those clear messages are usually too simple to tell the whole story and are often going to get the nation nowhere.
How many executives in large complex organizations are beginning to find that their ability to communicate complex operations in sound bites is more critical than ever. I think that maybe it has always been there; or as long as the Peter Principle has existed. Many a manager has scratched their head wondering how that person got promoted. Many a women manager has thrown back her shoulders in defiance of the fact that some guy who knew half as much got listened to and hence promoted. Maybe the political sound bite problem was born in complex business units and not in politics.
How do executives move beyond or even embrace the soundbite? A consistent, data driven and focused message can be crafted out of complex issues. It takes discipline and a "storyboard" to frame what you want to get across and how you want to be remembered in the decision-making process (so that your access increases). This in healthcare has been a particular problem for the safety and quality officer who has incredibly difficult process changes to explain; for the IT folks who need to steer the organization from the snazziest demo to a capital decision that balances long term goals and short term incentives. And the manager who manages the unique (the poor persons clinic) or the mundane (revenue cycle) or the executive who needs to invest capital for safety and not for glamorous hi-tech marketing friendly toys.
The story board needs to be graphic in that the message has to be seen, heard and understood immediately. It needs to also educate the audience about the opportunity this complicated matter has to either move the organization toward success or save it from disaster. Even the most mundane processes can be told in a way that the Board or top leadership team can see their success dependent on it.
I have had a client who was being relegated to the second tier of senior executives even though this exec had the largest budget and FTEs? Why, because the SVP was a "team player", a workhorse and did not communicate the importance of their product/processes to the CEO proactively but only reactively. Professional to a fault, this person was leading the team to potential budget cuts in some of the most complex and backbone operations because of this failure.
Disney designed the storyboard to hone their message. Each frame tells the story and makes a clear impression. Your storyboard can be bulletpoints but you have to know who the protoganist, antagonist, action and result are for each frame. 10 frames will tell your story.
How many executives in large complex organizations are beginning to find that their ability to communicate complex operations in sound bites is more critical than ever. I think that maybe it has always been there; or as long as the Peter Principle has existed. Many a manager has scratched their head wondering how that person got promoted. Many a women manager has thrown back her shoulders in defiance of the fact that some guy who knew half as much got listened to and hence promoted. Maybe the political sound bite problem was born in complex business units and not in politics.
How do executives move beyond or even embrace the soundbite? A consistent, data driven and focused message can be crafted out of complex issues. It takes discipline and a "storyboard" to frame what you want to get across and how you want to be remembered in the decision-making process (so that your access increases). This in healthcare has been a particular problem for the safety and quality officer who has incredibly difficult process changes to explain; for the IT folks who need to steer the organization from the snazziest demo to a capital decision that balances long term goals and short term incentives. And the manager who manages the unique (the poor persons clinic) or the mundane (revenue cycle) or the executive who needs to invest capital for safety and not for glamorous hi-tech marketing friendly toys.
The story board needs to be graphic in that the message has to be seen, heard and understood immediately. It needs to also educate the audience about the opportunity this complicated matter has to either move the organization toward success or save it from disaster. Even the most mundane processes can be told in a way that the Board or top leadership team can see their success dependent on it.
I have had a client who was being relegated to the second tier of senior executives even though this exec had the largest budget and FTEs? Why, because the SVP was a "team player", a workhorse and did not communicate the importance of their product/processes to the CEO proactively but only reactively. Professional to a fault, this person was leading the team to potential budget cuts in some of the most complex and backbone operations because of this failure.
Disney designed the storyboard to hone their message. Each frame tells the story and makes a clear impression. Your storyboard can be bulletpoints but you have to know who the protoganist, antagonist, action and result are for each frame. 10 frames will tell your story.
Friday, September 3, 2010
Lessons for healthcare from entrepreneurs
Thompson and Macmillan in this months HBR explored entrepreneurs in developing countries. Their experience resonates with healthcare as we move from a mature market to one resembling a developing market.
"Entrepreneurs and others who want to launch businesses in... environments [where they lack reliable data] need to put together the best models and mechanisms they can, documenting their assumptions as they go. Critically, however, they need to systematically test each of the assumptions underpinning their preliminary models against a series of checkpoints and be prepared to change on the fly, redirecting their efforts through a process known as discovery-driven planning. In this way, they can act on emerging evidence instead of obstinately and blindly pursuing infeasible objectives."
Discovery-driven planning is a critical focus for healthcare executives who traditionally move down roads that are well paved and well paid but may now have to build as they go. Listen to McGrath and Macmillan in their 1995 HBR article on discovery-driven planning. "New ventures are undertaken with a high ratio of assumption to knowledge. With ongoing businesses, one expects the ratio to be the exact opposite. Because assumptions about the unknown generally turn out to be wrong, new ventures inevitably experience deviations—often huge ones—from their original planned targets. Indeed, new ventures frequently require fundamental redirection."
Their focus on discovery-driven planning, following a model where the newly acquired experience and data drive the design of the enterprise is a real opportunity for those who want to move to the head of the pack in the era of health reform.
"Entrepreneurs and others who want to launch businesses in... environments [where they lack reliable data] need to put together the best models and mechanisms they can, documenting their assumptions as they go. Critically, however, they need to systematically test each of the assumptions underpinning their preliminary models against a series of checkpoints and be prepared to change on the fly, redirecting their efforts through a process known as discovery-driven planning. In this way, they can act on emerging evidence instead of obstinately and blindly pursuing infeasible objectives."
Discovery-driven planning is a critical focus for healthcare executives who traditionally move down roads that are well paved and well paid but may now have to build as they go. Listen to McGrath and Macmillan in their 1995 HBR article on discovery-driven planning. "New ventures are undertaken with a high ratio of assumption to knowledge. With ongoing businesses, one expects the ratio to be the exact opposite. Because assumptions about the unknown generally turn out to be wrong, new ventures inevitably experience deviations—often huge ones—from their original planned targets. Indeed, new ventures frequently require fundamental redirection."
Their focus on discovery-driven planning, following a model where the newly acquired experience and data drive the design of the enterprise is a real opportunity for those who want to move to the head of the pack in the era of health reform.
Some thoughts on how to move forward to a Reform Agenda
Do you have a plan? Is it more control over doctors, EHR and push back on any rate reductions? These are some insights into ways to begin to move your organization toward a sustainable future.
Friday, August 20, 2010
Think ATMs
California's TeleHealth project (InformationWeek) that has the potential to link providers in 900 hospitals in California is an amazing step forward for streamlining healthcare and creating greater access to quality. Just beginning, it holds the potential to decrease unnecessary testing, tap experts at other centers and stretch resources across the California healthcare landscape. The result, hopefully, is reduced cost and greater quality.
But what after California? Is this a state-by-state system ? Or like the banking systems that allowed access to your own financial information through ATMs almost anywhere in the US and often abroad, is it an integrated standardized system? The National Health Information Network is the long term goal although it appears to be happening state by state. This makes the investment in hospital and physician technology critical and daunting for smaller hospitals and primary care physicians, as stand alone banks a few decades ago found out as the banking system became national and multinational. But the Federal government has created Regional Extension Centers (RECs) to support 100,000 primary providers in 2 years.
The possibilities are out there. Broadband technology is in use organization by organization but what is next for the system. How far can we go to access our health information? And which states will follow California?
But what after California? Is this a state-by-state system ? Or like the banking systems that allowed access to your own financial information through ATMs almost anywhere in the US and often abroad, is it an integrated standardized system? The National Health Information Network is the long term goal although it appears to be happening state by state. This makes the investment in hospital and physician technology critical and daunting for smaller hospitals and primary care physicians, as stand alone banks a few decades ago found out as the banking system became national and multinational. But the Federal government has created Regional Extension Centers (RECs) to support 100,000 primary providers in 2 years.
The possibilities are out there. Broadband technology is in use organization by organization but what is next for the system. How far can we go to access our health information? And which states will follow California?
Wednesday, August 18, 2010
Evaluating capital decisions in the new era (AR:after reform)
I am dating myself but I went to school when 2011 years ago was BC. For my newly educated almost adult children BC is BCE(Before Common Era) and AD is CE (Common Era). I don't know what is so common about it, but I digress. So I am calling this new health era that we are in 1 AR (after reform). I think it is better than AO (after Obamacare) because I find that title somewhat awful! (You could also call it After Recession, but I am not sure we would know when to start counting.)
So in this new time, how will decision-making processes change for CEOs and Boards. OR should they? Especially on big strategic investments and overall capital spending.
Is it a time to continue status quo and build a better mousetrap? Or is it time to retool (think auto companies, but they had a bailout)? Or is it all in IT and infrastructure? What are you doing with bricks and mortar? How are you tying these decisions to the overall economics and demographics of your community?
Only three short years ago, the capital race to build it better than the guy down the street was on full tilt. More new hospitals went up or were on the drawing board with little change in business plan. Yeah, there were a few that were creating the ER for bioterrorism, or were going green but in terms of the basic hospital model of inpatient care at 4.6 days LOS, not much was changing.
As discussions of consolidation, community health centers, accountable care organizations and networks loom, how is it affecting capital decision-making? Is your capital assessment strategy the same (cutting edge, tried and true or whatever level you were in BR (before reform and recession).
As the medical cost index dipped for only the 6th month in 63 years, is it a bleap or a new era?
What should your board be asking?
Investment in the independent hospital unless you are the sole community provider seems to be premature at this point. Opportunities to expand ambulatory facilities, virtual care through internet, smart phones for doctors, fully integrated EHR may be how you differentiate in this era. Investments in safety features, outpatient labs, inhome monitoring capability of chronic patients may tie those patients to your facility more than the shiny tower.
In looking at the assessment strategy, only those with major research capabilities should be jumping in to alpha and beta site new technology. The proven workhorse that can sustain your organization longer term may be the better investment, regardless of the EMR incentives from Medicare.
When we look back from 10 AR what investments will have made the difference? And which were a waste?
So in this new time, how will decision-making processes change for CEOs and Boards. OR should they? Especially on big strategic investments and overall capital spending.
Is it a time to continue status quo and build a better mousetrap? Or is it time to retool (think auto companies, but they had a bailout)? Or is it all in IT and infrastructure? What are you doing with bricks and mortar? How are you tying these decisions to the overall economics and demographics of your community?
Only three short years ago, the capital race to build it better than the guy down the street was on full tilt. More new hospitals went up or were on the drawing board with little change in business plan. Yeah, there were a few that were creating the ER for bioterrorism, or were going green but in terms of the basic hospital model of inpatient care at 4.6 days LOS, not much was changing.
As discussions of consolidation, community health centers, accountable care organizations and networks loom, how is it affecting capital decision-making? Is your capital assessment strategy the same (cutting edge, tried and true or whatever level you were in BR (before reform and recession).
As the medical cost index dipped for only the 6th month in 63 years, is it a bleap or a new era?
What should your board be asking?
- What does this technology do to tie the patient into the system longer term and help manage their care?
- Is this redundant in the marketplace and can we be the best at it when the scorecards come out?
- How will we use this investment to reduce operating costs?
Investment in the independent hospital unless you are the sole community provider seems to be premature at this point. Opportunities to expand ambulatory facilities, virtual care through internet, smart phones for doctors, fully integrated EHR may be how you differentiate in this era. Investments in safety features, outpatient labs, inhome monitoring capability of chronic patients may tie those patients to your facility more than the shiny tower.
In looking at the assessment strategy, only those with major research capabilities should be jumping in to alpha and beta site new technology. The proven workhorse that can sustain your organization longer term may be the better investment, regardless of the EMR incentives from Medicare.
When we look back from 10 AR what investments will have made the difference? And which were a waste?
Making it work for less
The article in USA Today documents the need for payment to physicians for phone and email contact with patients. http://www.usatoday.com/news/health/2010-08-16-1Aprimarycare16_CV_N.htm?loc=interstitialskip
I would take it one step further and suggest that primary care physicians that check in with all the subspecialists on a complex patient should get paid for that communication too. The result, better care, lower cost, BENDING THE COST CURVE for most patients.
The article also highlights those practices that didn't wait til the payment was just right to start doing the next best thing. They did what they needed to do to prove their model works. How: transition plannning. They enlisted their patients in paying a fee for the model. Might not work everywhere but managing the transition is going to be the big issue for all practices big and small.
I would take it one step further and suggest that primary care physicians that check in with all the subspecialists on a complex patient should get paid for that communication too. The result, better care, lower cost, BENDING THE COST CURVE for most patients.
The article also highlights those practices that didn't wait til the payment was just right to start doing the next best thing. They did what they needed to do to prove their model works. How: transition plannning. They enlisted their patients in paying a fee for the model. Might not work everywhere but managing the transition is going to be the big issue for all practices big and small.
Tuesday, August 17, 2010
Small changes make big differences in safety and cost
Another fascinating study by the U of M. Not only did they prove that reminder systems that cut through the human error/red tape conundrum work for reducing Catheter-aquired UTIs but they went on to study whether the Medicare regs meant to encourage this kind of activity served as an incentive. http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=1683. What did they find? That their system, especially computerized reminders at log-on and empowering nursing to make a catheter removal decision decreased infections by 52%. This is important for other common hospital acquired infections also. Even hand washing reminders could pop up at log-on! But sadly only 1 in 10 hospitals currently have these systems in place.
But what I found fascinating was the second part of the article that the Medicare regs while appearing to be an incentive to change behavior, in actuality had no economic impact because most hospitals don't document these properly. So the hospitals that don't change really won't be effected. You can blame the Medicare bureaucrats, but I bet the hospital management at most hospitals had no idea how they bill for CAUTIs. (I for one didn't!)
What is the lesson? The lesson should be that these ideas are the saviors of the healthcare system because they will allow hospitals to cut unnecessary costs on inpatient admissions and readmissions as they move to a more ambulatory based presence. However if they don't see the self interest will patients and communities demand change in quality and safety regardless of whether hospitals get paid? And as they get educated, will they choose the safer hospital? Not sure that the consumer of healthcare is in the driver-seat quite yet.
But what I found fascinating was the second part of the article that the Medicare regs while appearing to be an incentive to change behavior, in actuality had no economic impact because most hospitals don't document these properly. So the hospitals that don't change really won't be effected. You can blame the Medicare bureaucrats, but I bet the hospital management at most hospitals had no idea how they bill for CAUTIs. (I for one didn't!)
What is the lesson? The lesson should be that these ideas are the saviors of the healthcare system because they will allow hospitals to cut unnecessary costs on inpatient admissions and readmissions as they move to a more ambulatory based presence. However if they don't see the self interest will patients and communities demand change in quality and safety regardless of whether hospitals get paid? And as they get educated, will they choose the safer hospital? Not sure that the consumer of healthcare is in the driver-seat quite yet.
Monday, August 16, 2010
The cold truth
Okay so they are not death panels, but there is a big whopping barrier to healthcare, ie. good healthcare. No its not the insurance guy keeping you away from the door. Its the fact that you are without insurance, or on Medicaid and are a minority.
So what is news about that...we have heard about the uninsured every day for the past two years of the healthcare debate and its getting kind of boring. Well its not so boring if you are a tax payer. As it turns out the emergency room fantasy that everyone has care if they are really sick, means that the sickest folks are in the ER and poor. They require an ER when the rest of us get an annual mammogram to detect cancer.
I just completed the first phase of a study on cancer patients at an academic medical center and a county hospital. Suffice it to say the the patient looks very different in the oncology department at the academic medical center than at the county hospital. The AMC patient is more frequently insured and white and likely to be at any stage of a cancer. The County patient is uninsured, minority and 50% likely to be end stage cancer.
Who of these patients make it to their appointments to insure a chance of survival. You guessed it the AMC patient has a statistical advantage that they will make their appointments. But the interesting thing is if the AMC patient is not white or insured, their likelihood of making it to their treatment drops significantly.
So why am I sharing this observation? Because the system as currently structured is too difficult to access early diagnosis and treatment if you are poor. In addition, the system is too difficult and time consuming and expensive even if you are at the best places for care. It takes a village and if you don't have one, your outcomes will be poor.
What has an impact on this equation. So far it looks like patient navigation, or the staff who dedicate their time to overcome barriers to care for patients. It seems to work. It doesn't balance the disparity of being poor in this county but it lessens the load and statistically improves outcomes. Kudos to organizations like the American Cancer Society in Illinois for taking on Navigation as a priority.
So what does this mean for reform? More resources in patients emotional and social support are going to bend the cost curve. And even more importantly, targeted early intervention for high risk groups. Annual screenings and check-ups for those that never thought it was in their price point may be the difference between costly treatments in the last 6 months and treatments that improve the quality of life.
So what is news about that...we have heard about the uninsured every day for the past two years of the healthcare debate and its getting kind of boring. Well its not so boring if you are a tax payer. As it turns out the emergency room fantasy that everyone has care if they are really sick, means that the sickest folks are in the ER and poor. They require an ER when the rest of us get an annual mammogram to detect cancer.
I just completed the first phase of a study on cancer patients at an academic medical center and a county hospital. Suffice it to say the the patient looks very different in the oncology department at the academic medical center than at the county hospital. The AMC patient is more frequently insured and white and likely to be at any stage of a cancer. The County patient is uninsured, minority and 50% likely to be end stage cancer.
Who of these patients make it to their appointments to insure a chance of survival. You guessed it the AMC patient has a statistical advantage that they will make their appointments. But the interesting thing is if the AMC patient is not white or insured, their likelihood of making it to their treatment drops significantly.
So why am I sharing this observation? Because the system as currently structured is too difficult to access early diagnosis and treatment if you are poor. In addition, the system is too difficult and time consuming and expensive even if you are at the best places for care. It takes a village and if you don't have one, your outcomes will be poor.
What has an impact on this equation. So far it looks like patient navigation, or the staff who dedicate their time to overcome barriers to care for patients. It seems to work. It doesn't balance the disparity of being poor in this county but it lessens the load and statistically improves outcomes. Kudos to organizations like the American Cancer Society in Illinois for taking on Navigation as a priority.
So what does this mean for reform? More resources in patients emotional and social support are going to bend the cost curve. And even more importantly, targeted early intervention for high risk groups. Annual screenings and check-ups for those that never thought it was in their price point may be the difference between costly treatments in the last 6 months and treatments that improve the quality of life.
Monday, August 9, 2010
Where is AARP when you need them?
We do not need protection from death panels, but we do need advocacy about hospice, rehab, home health and specialty clinics. Physical therapy is one of the leading barriers to an Emergency Room admission. Long term care as an independent outpatient is the key to admission avoidance. So why are we reining in medicare rehab and cutting back on hospice. These are services that make geriatric living work...and work independently and without nursing homes and with ERs and without ICUs. Let's rethink quality of life. It isn't being attended to by a swashbuckling surgeon but being calmly led to independence by a PT!
Facing Facts
Its monday and I either don't have enough tools and beds to make everyone happy or I have too many beds and tools and I am worrying about census and nashing my teeth about how in the short run to make it work. I know that the community isn't served equally and there are quality gaps that I could fill but I dont' have the resources. So what do I do?
Good question. You might want to consider buying the specialty practices that are crying about medicare funding. Buy you know that you really need to invest in primary care. How do you manage the change? How do you move through the transition in a meaningful way that doesn't bankrupt the house. Resist and yet move fast! How is that the strategy? How do you build the ambulatory care and let the specialty, the breadwinner, work its way through your fog? How do you extend your productivity in your least ROI guys and shrink the productivity in the most ROI guys? You just do. You figure out the balance and you slowly move in that direction and you bring folks along and you drop certain folks that don't meet standards along the way
This is tough work and don't do it alone. It requires a steel spine and a couple friends to get through it!
But the good news is they are predicting that the Medicare trust fund will be solvent for 20 more years...but only if you do the work that needs to be done!
Good question. You might want to consider buying the specialty practices that are crying about medicare funding. Buy you know that you really need to invest in primary care. How do you manage the change? How do you move through the transition in a meaningful way that doesn't bankrupt the house. Resist and yet move fast! How is that the strategy? How do you build the ambulatory care and let the specialty, the breadwinner, work its way through your fog? How do you extend your productivity in your least ROI guys and shrink the productivity in the most ROI guys? You just do. You figure out the balance and you slowly move in that direction and you bring folks along and you drop certain folks that don't meet standards along the way
This is tough work and don't do it alone. It requires a steel spine and a couple friends to get through it!
But the good news is they are predicting that the Medicare trust fund will be solvent for 20 more years...but only if you do the work that needs to be done!
Thursday, August 5, 2010
Why can't patients schedule their visits themselves....
I expect that I can schedule every appointment by computer/email access. Is that my reality? Unfortunatley not. I can schedule my car, my kids, my travel, my hair but not my primary care visit, my derm checkup, my endoscopy (okay maybe I should check in first with my GI). I dial one number and repeat a couple numbers for my perscriptions, I register on line for every move I make in terms of restaurants and hotels and rental cars etc...so why can't I just schedule myself for an appointment without having to talk to two clerks and an electronic dialer to get an appointment. Why can't I see the schedule options and do my mammogram and bone scan and blood test on the same day. Why can't my annual visit for a skin scan and gyne appointment and primary care checkup all follow one another so I can get it done in the one day I take off. Am I really unreasonable or is it possible that I can have some control over my schedule.
Do we need a navigator for all our visits or do we need a system that allows visits to be scheduled in a way that we might make them. Okay, if I need radiation therapy, they can still dictate the schedule (or at least for the first week!).
Do we need a navigator for all our visits or do we need a system that allows visits to be scheduled in a way that we might make them. Okay, if I need radiation therapy, they can still dictate the schedule (or at least for the first week!).
Tuesday, August 3, 2010
Time to think outside the box
Maybe I am awaking to a whole new planet out there. When my daughter stepped off the plane from Rwanda yesterday I realized that I too mentally went with her, tracking all things African over the last several weeks. A place that I never thought I would step foot in, all of a sudden had a tremendous appeal. I think that we in America are so used to tooting our own horn and adoring all things Western that we often fail to look outside our borders for solutions. The world may be becoming more global but in our thinking about our own problems, we seem to be more inward thinking and often stuck. We are feeding on ourselves instead of growing new ideas.
So what does any of that rambling have to do with Healthcare. Check out this months Health Affairs for models of what works and what doesn't in other nations not just in Europe but in Africa as well. The focus on primary care and prevention worldwide has some lessons for us.
Are we questioning our medical education system adequately? Look at the article on nurse anesthetist quality and the article on international graduates quality. Our system is costly and slow and culturally difficult to change. What if as in Spain, where I met young medical students who started their training Freshman year - not in premed but in 5 year medical school? What if that model worked for primary care practitioners? That might save the average primary care physician about $200,000 in tuition costs and begin their productive years as a new physician 3-4 years earlier. The pressure on starting salaries and the attractiveness of primary care may be positively affected. Read also about Spain's impact on health outcomes and the cost of their system.
Just thinking.....
So what does any of that rambling have to do with Healthcare. Check out this months Health Affairs for models of what works and what doesn't in other nations not just in Europe but in Africa as well. The focus on primary care and prevention worldwide has some lessons for us.
Are we questioning our medical education system adequately? Look at the article on nurse anesthetist quality and the article on international graduates quality. Our system is costly and slow and culturally difficult to change. What if as in Spain, where I met young medical students who started their training Freshman year - not in premed but in 5 year medical school? What if that model worked for primary care practitioners? That might save the average primary care physician about $200,000 in tuition costs and begin their productive years as a new physician 3-4 years earlier. The pressure on starting salaries and the attractiveness of primary care may be positively affected. Read also about Spain's impact on health outcomes and the cost of their system.
Just thinking.....
Thursday, July 22, 2010
Real Solutions
My daughter (16) is in Rwanda with WE ACTx* helping with a camp for HIV-infected teens. They visited an incredible project designed to overcome the poverty and famine of the region. We in the US need to start thinking some of these insoluble problems are opportunities for audacious thinking and lose our fear of the unknown. Look what creative people focused on the right goal can do. http://www.millenniumvillages.org/aboutmv/mv_mayange.htm
What lens are you looking through toward the future?
*WE-ACTx is an international community-based initiative that was launched in fall 2003 by frontline AIDS physicians, activists and researchers with extensive ...
www.we-actx.org/
What lens are you looking through toward the future?
*WE-ACTx is an international community-based initiative that was launched in fall 2003 by frontline AIDS physicians, activists and researchers with extensive ...
www.we-actx.org/
Real caring
Health Affairs published a truly thoughtful article (blog) about the reality of caring and the culture for caring. It is well worth the read. Dr. Han's comparisons of our reaction to the tragedy in Haiti and our response to our own health crisis in this country is thoughtful and long overdue. Anyone who works on the provider side of healthcare knows how much his experience rings true. It may be an eye-opener for the non-provider and brings a face to the incredible disconnects in the system.http://healthaffairs.org/blog/2010/07/21/calculating-caring/
Tuesday, July 20, 2010
Paradigm shift for CEOs
Inpatient is the revenue driver. More admissions are better. Shorter LOS is the solution. Employee physicians to control them. Every bed and hospital is needed. Emergency rooms will be perpetually overcrowded without more high tech ERs or beds. Nursing is an inpatient profession. Medical Records are the hospitals property. If everyone were insured, there would be financial stability in the hospital sector.
Are you bored yet with the list? So what's the point, you ask?
I suggest that you take a fresh look at the list. And when you have tipped these notions upside down, you might be starting to work toward Reform solutions. I also suggest that you relook at who is in charge and where the power in the organization needs to go. The hospital CEO just may become just that and nothing else....which may not be the top of the heap. The hospital will be a cost center operation...not necessarily a revenue center.
How do your clinics look? How competitive are they? How loyal are your doctors and how tied in are they? Whose software is going in their offices? Who is going to take care of all your newly insured but difficult patients?
The safety net that the hospital's bought with a pass from the Indepent Payment Advisory Commission may cause this to roll through in ways that complicate your efforts to reform. Hospital's need to get behind money for rehab, primary physicians, specialty chronic disease clinics that help them bridge the new world.
As costs go up nationally, the hammer will come down. Will you be ready?
Are you bored yet with the list? So what's the point, you ask?
I suggest that you take a fresh look at the list. And when you have tipped these notions upside down, you might be starting to work toward Reform solutions. I also suggest that you relook at who is in charge and where the power in the organization needs to go. The hospital CEO just may become just that and nothing else....which may not be the top of the heap. The hospital will be a cost center operation...not necessarily a revenue center.
How do your clinics look? How competitive are they? How loyal are your doctors and how tied in are they? Whose software is going in their offices? Who is going to take care of all your newly insured but difficult patients?
The safety net that the hospital's bought with a pass from the Indepent Payment Advisory Commission may cause this to roll through in ways that complicate your efforts to reform. Hospital's need to get behind money for rehab, primary physicians, specialty chronic disease clinics that help them bridge the new world.
As costs go up nationally, the hammer will come down. Will you be ready?
Monday, July 19, 2010
Prevention may be your main product line
While patients should be focused on Inpatient QI indicators and Patient Safety indicators, Hospital leaders are hopefully transitioning their resources into AHRQ's Prevention Indicators. Prevention has gotten lots of lip service in the past, but your performance may become the bread and butter driver of financial performance, differentiating you from others in the market.
Do you know how many admissions were for short and long term diabetic complications? Do you know how it compares to your competitors? Do you know your rates of Pediatric asthma admissions? Perforated Appendices? What are your rates of admission for COPD and CHF? What about UTIs?
The future relationship with your medical staff (or accountable care organization) is going to be about admissions avoided, healthier populations, consistent ambulatory standards and fewer admissions.
Growth in admissions in the past 10 years while assumed to be skewed toward the aging population is really reflective of a major increase in 45-64 year olds, procedures and chronic conditions. Over 70% of admissions was the result of a chronic condition or the chronic condition was a co-morbidity.
The cost curve bending will be in the form of per admission revenue if health systems are not bending the curve through more appropriate ambulatory delivery models? (Don't let the Medicare cut protection lull you into thinking you have time...Medicaid will be a greater issue for many hospitals.)
Do any of these indicators show up on your key indicators of performance? Does your Board know that this is their business model into the future?
Do you know how many admissions were for short and long term diabetic complications? Do you know how it compares to your competitors? Do you know your rates of Pediatric asthma admissions? Perforated Appendices? What are your rates of admission for COPD and CHF? What about UTIs?
The future relationship with your medical staff (or accountable care organization) is going to be about admissions avoided, healthier populations, consistent ambulatory standards and fewer admissions.
Growth in admissions in the past 10 years while assumed to be skewed toward the aging population is really reflective of a major increase in 45-64 year olds, procedures and chronic conditions. Over 70% of admissions was the result of a chronic condition or the chronic condition was a co-morbidity.
The cost curve bending will be in the form of per admission revenue if health systems are not bending the curve through more appropriate ambulatory delivery models? (Don't let the Medicare cut protection lull you into thinking you have time...Medicaid will be a greater issue for many hospitals.)
Do any of these indicators show up on your key indicators of performance? Does your Board know that this is their business model into the future?
Wednesday, July 7, 2010
Don Berwick
Congrats to President Obama for moving ahead with this appointment. The cost curve doesn't bend without data applied rationally. Dr. Berwick is respected by the hospitals that he has guided toward making quantitative leaps in quality and safety. Only with thoughtful leadership is there going to be change that is sustainable and not strictly political.
Tuesday, June 15, 2010
What evidence?
The recent Health Affairs article proclaims "Some consumers are wary of evidence based healthcare". And I say to that, "they should be!" "What a heretic, how backward can you be?" you are asking yourself and me. My response "Where did they get the evidence?" When every study to-date except the recent Group Health Cooperative Medical Home study suggests that doctors listen to their patients for 13-30 seconds and that is really generous, before they go off on a diagnostic path of their own evidenced by interupting the patient and ceasing to listen. Patient, after trusting patient, stops telling their doctors anything, assuming as my father does that someone has read his records before he came in that day, because they seem so on top of it that they don't need to hear from him. Or the women that trusted their cardiologists as they applied evidence from male only studies for 20 years.
The Medical Home information is about slowing down the most critical process, the office visit from whence all the tests and treatments begin. The idea is that someone might ask questions beyond the first 30 seconds and might listen to the whole story. They might hear that it really is indigestion and not heart disease or vice versa. They might hear the dementia. They might check a reference book or email a specialists for a second opinion before taking the high risk patient off his coumidin for a minor procedure.
I get the wariness; I get the weariness of many patients who have probably had minor and major procedures that treated one symptom and not the whole problem, leaving that to its more costly course later down the road. Evidence directed care, yes, but could we begin to use a bit more evidence when heading down these paths. And maybe clue the patient in to where the path is leading.
The Medical Home information is about slowing down the most critical process, the office visit from whence all the tests and treatments begin. The idea is that someone might ask questions beyond the first 30 seconds and might listen to the whole story. They might hear that it really is indigestion and not heart disease or vice versa. They might hear the dementia. They might check a reference book or email a specialists for a second opinion before taking the high risk patient off his coumidin for a minor procedure.
I get the wariness; I get the weariness of many patients who have probably had minor and major procedures that treated one symptom and not the whole problem, leaving that to its more costly course later down the road. Evidence directed care, yes, but could we begin to use a bit more evidence when heading down these paths. And maybe clue the patient in to where the path is leading.
"imponderingly complex technical society"
David Brooks of the New York Times wrote an OpEd piece on May 27 http://www.nytimes.com/2010/05/28/opinion/28brooks.html?scp=1&sq=drlling%20for%20certainty&st=Search about the dangers of managing in our technologically intricate society. Of course he was referring to the BP "spill".
He looks at a number of points but as he points out so eloquently "This isn't just about oil. It's a challenge for people living in an imponderably complex technical society". And that society as we well know includes healthcare. I think BP could have learned from our experience of the last decade but we too could continue to be reminded of the perils of being "placed in situations too complicated to understand".
So his points are as follows:
1. "(P)eople have trouble imagining how small failings combine to lead to catastrophic disasters".
2. "People have a tendency to get acclimated to risk".
3. "People have a tendency to place elaborate faith in backup systems and safety devices"
4. "People have a tendency to match complicated technical systems with complicated governing structures"
5. "People tend to spread good news and hide bad news".
6. "People in the same field begin to think alike whether they are in oversight roles or not".
This is a great set of reminder to keep in front of management, medical leaders and the board. Even though we have many great minds outlining the paths to safe and effective care, we are not there yet. In fact, as the model changes with reform adding more complexity to the system, we would be wise to reflect on these with our Boards. The authority matrix alluded to in Mr. Brooks fourth point and the Governance responsibility in the last point are well worth considering as we head into the next chapter in health care delivery in a very complex and potentially dangerous system.
He looks at a number of points but as he points out so eloquently "This isn't just about oil. It's a challenge for people living in an imponderably complex technical society". And that society as we well know includes healthcare. I think BP could have learned from our experience of the last decade but we too could continue to be reminded of the perils of being "placed in situations too complicated to understand".
So his points are as follows:
1. "(P)eople have trouble imagining how small failings combine to lead to catastrophic disasters".
2. "People have a tendency to get acclimated to risk".
3. "People have a tendency to place elaborate faith in backup systems and safety devices"
4. "People have a tendency to match complicated technical systems with complicated governing structures"
5. "People tend to spread good news and hide bad news".
6. "People in the same field begin to think alike whether they are in oversight roles or not".
This is a great set of reminder to keep in front of management, medical leaders and the board. Even though we have many great minds outlining the paths to safe and effective care, we are not there yet. In fact, as the model changes with reform adding more complexity to the system, we would be wise to reflect on these with our Boards. The authority matrix alluded to in Mr. Brooks fourth point and the Governance responsibility in the last point are well worth considering as we head into the next chapter in health care delivery in a very complex and potentially dangerous system.
Monday, June 14, 2010
Lots to celebrate
I am doing alot of thinking about the good old days....not about healthcare but about my son who just graduated and how old I really must be....my high school graduation was 3...years ago...I couldn't write the last digit..I am in denial.
And when I told his friends they were all like Eddie Haskell and they looked at me like I had lost my mind, I thought, maybe I just never got along with high school boys.
And those kids who won the Stanley cup and were dancing to 2 million fans. They were born in the late 1980s. The Blackhawks were guys that had made it....how could they have made it if they were born yesterday.
Okay Prom really did it to me! I could not believe that a whole generation and a few extra years had passed since my high school prom. Of course, it didn't matter to me at the time, I didn't even go, but now that my son was going with a beautiful young lady, I could not get over how I was no longer a kid.
I can hear the screams of just grow up...its about time. Its not as if I haven't had mature and even senior moments in the past; this just cemented it in a way that was way too visceral.
I hate to say that my blog this morning on reform felt similar...I could recall all the major changes in healthcare over the last 30 years starting with the switch from pure fee for service to cost based budgeting. Then to revenue caps, then to DRGs, and managed care and IPAs and POSs and then to the IOM study and on and on... I wonder whether all that history is a good thing. I think so in many ways because I have lived through accountable care organizations - when I worked for Group Health - and working toward a single payor system in Washington State and Medicaid expansion and the move to ambulatory care and corporate practice of medicine and safety vs. tort reform.
But somehow I don't feel old. I feel experienced. And I feel energized to figure out how to make this work for Americans who don't feel it works now.
I wonder whether that is the same feeling out there...that what's new is great, that we can't rest on our laurels and ride it out to retirement; that this is the moment for true creativity, and value creation based on real data and real experience.
And when I told his friends they were all like Eddie Haskell and they looked at me like I had lost my mind, I thought, maybe I just never got along with high school boys.
And those kids who won the Stanley cup and were dancing to 2 million fans. They were born in the late 1980s. The Blackhawks were guys that had made it....how could they have made it if they were born yesterday.
Okay Prom really did it to me! I could not believe that a whole generation and a few extra years had passed since my high school prom. Of course, it didn't matter to me at the time, I didn't even go, but now that my son was going with a beautiful young lady, I could not get over how I was no longer a kid.
I can hear the screams of just grow up...its about time. Its not as if I haven't had mature and even senior moments in the past; this just cemented it in a way that was way too visceral.
I hate to say that my blog this morning on reform felt similar...I could recall all the major changes in healthcare over the last 30 years starting with the switch from pure fee for service to cost based budgeting. Then to revenue caps, then to DRGs, and managed care and IPAs and POSs and then to the IOM study and on and on... I wonder whether all that history is a good thing. I think so in many ways because I have lived through accountable care organizations - when I worked for Group Health - and working toward a single payor system in Washington State and Medicaid expansion and the move to ambulatory care and corporate practice of medicine and safety vs. tort reform.
But somehow I don't feel old. I feel experienced. And I feel energized to figure out how to make this work for Americans who don't feel it works now.
I wonder whether that is the same feeling out there...that what's new is great, that we can't rest on our laurels and ride it out to retirement; that this is the moment for true creativity, and value creation based on real data and real experience.
I took a break....
After all the buzz around health reform, then health insurance reform, then no reform, then yes reform....I like all my colleagues in health management had to take a giant breath and regroup. No longer were we wondering "if and when" but now it was "oh my", "how and why" or "so what". I had to come off the policy and political junkie high and continue to think through the reality of expanding care. I had to think through the reality of expanding the national deficit. And I had to get my hands around the one true fact - there will not be more money but less for what we currently see as healthcare and there will be more money and power in what we traditionally have undervalued.
So it was interesting to me when 85% of a recent survey of CEOs announced that they had plans in place to deal with reform! Do you really? That was kind of interesting to me given that the healthcare world that I know grew up with competition, not health planning and with an internal view of healthcare from an institutional perspective not from a consumer or god-forbid a community perspective. So what is it that health leaders are doing?
It seems that there is understandably a huge focus (read huge potential outlay of capital) on IT and EMR. This is so understandable and so right for a small percentage of organizations (read major systems). For small or independent hospitals it seems like the cart before the horse. Is this record ambulatory or inpatient - is it portable? What is your size and can you continue to manage risk and inpatient operations for a defined population? If not, will you be purchasing other hospitals and clinics, or will you be looking to partner to expand your capacity for change? What system will they have just purchased and do you have the capital to integrate? What change will the new system drive - that is the key question.
The second area of great strategic effort is on physician relations. Does that mean opening clinics - how many makes sense - what is the ratio of ambulatory to inpatient beds? Are you employing subspecialists - based on what? Medicare cuts or community need? Where are your primary care physicians going to come from? Do your bylaws allow midwifes, PAs etc? Have you bundled payments since your IPA days and how successful was it? Who took the risk?
Is this a strange new world; that may not be so new but certainly will be strange. When in 1980, I worked for Group Health Cooperative of Puget Sound, we had 28 clinics and 3 specialty centers (read doctors and procedures) for 3 small hospitals. The hospitals were not where the power was. Is your ambulatory care at a size and breadth to assure financial sustainability as you move more and more to ambulatory care. If you add one to two days of care to replace a 4 day readmission do you have a queue in your clinics to fill the capacity?
What is your plan for Medicaid expansion? Are you in a state where Medicaid is underfunded and the costs of care are not covered? What about DSH hospitals - what will you do without that added payment?
Can you afford the transition of a revenue generating inpatient facility to a cost center inpatient facility?
This is an exciting time but the fixes are systemic not peripheral. This is much less about who pays than on who delivers!
I am not sure if this brave new world is as well understood by those responding to the survey. I think the questions outnumber the answers right now, but the one thing you can count on is that there will be more financial pressure than relief as you go through the change.
And as I say to those I coach, its not only the system that has to change, its you!
So it was interesting to me when 85% of a recent survey of CEOs announced that they had plans in place to deal with reform! Do you really? That was kind of interesting to me given that the healthcare world that I know grew up with competition, not health planning and with an internal view of healthcare from an institutional perspective not from a consumer or god-forbid a community perspective. So what is it that health leaders are doing?
It seems that there is understandably a huge focus (read huge potential outlay of capital) on IT and EMR. This is so understandable and so right for a small percentage of organizations (read major systems). For small or independent hospitals it seems like the cart before the horse. Is this record ambulatory or inpatient - is it portable? What is your size and can you continue to manage risk and inpatient operations for a defined population? If not, will you be purchasing other hospitals and clinics, or will you be looking to partner to expand your capacity for change? What system will they have just purchased and do you have the capital to integrate? What change will the new system drive - that is the key question.
The second area of great strategic effort is on physician relations. Does that mean opening clinics - how many makes sense - what is the ratio of ambulatory to inpatient beds? Are you employing subspecialists - based on what? Medicare cuts or community need? Where are your primary care physicians going to come from? Do your bylaws allow midwifes, PAs etc? Have you bundled payments since your IPA days and how successful was it? Who took the risk?
Is this a strange new world; that may not be so new but certainly will be strange. When in 1980, I worked for Group Health Cooperative of Puget Sound, we had 28 clinics and 3 specialty centers (read doctors and procedures) for 3 small hospitals. The hospitals were not where the power was. Is your ambulatory care at a size and breadth to assure financial sustainability as you move more and more to ambulatory care. If you add one to two days of care to replace a 4 day readmission do you have a queue in your clinics to fill the capacity?
What is your plan for Medicaid expansion? Are you in a state where Medicaid is underfunded and the costs of care are not covered? What about DSH hospitals - what will you do without that added payment?
Can you afford the transition of a revenue generating inpatient facility to a cost center inpatient facility?
This is an exciting time but the fixes are systemic not peripheral. This is much less about who pays than on who delivers!
I am not sure if this brave new world is as well understood by those responding to the survey. I think the questions outnumber the answers right now, but the one thing you can count on is that there will be more financial pressure than relief as you go through the change.
And as I say to those I coach, its not only the system that has to change, its you!
Thursday, May 27, 2010
What is the right amount of management.
I loved reading the article on Paul Levy's blog a few back on "is your organization too flat?" Throughtout my career, when faced with a management challenge I have tended to want to bring more management attention to it and provide them with enought room to be thoughtful about their approach. However, every tie I have been confronted by management "experts" in the form of national management consulting gurus, I have found that they demand a flattening of the organization, relying on the advice and analysis of the most junior advisors to the point where it seemed not only counterintuitive but down right wrong. What I also found is that it was impossible to ever buck that common wisdom without looking like you were completely out of touch and even though the Board would have given you your walking papers when the proposal to flatten came along if you had objected, they always agreed to add those people back in 18 to 36 months later usually lamenting that we never ever got the marketing or whatever off the ground and that was what was holding us back. http://runningahospital.blogspot.com/2010/05/is-your-organization-too-flat.html .
The thinking of the study authors that Paul Levy quotes is just that, that at a time with difficult challenges and cost or quality problems, is flattening the best solution. Might the situation need more managment and not less. Might the span of control lend itself to change better with greater hands on supervision and role modeling. Might the operating results be better in the short and long term by keeping good managment in place and seeking moe good management.
I have recently adviced clients that had alot of management to streamline. Why? Because the accountability was poorly defined, the roles were poorly defined and the managment culture was weak. They need more managment but not on top of what they had but instead of.
I had another client that was getting limited results from management. It was not because there were not enough, or that they were not competent, it was about the expectations and the QI processes in place to getthat team into a innovative mode. They were so bogged down by bureaucracy and history that they could not see their way out. Leadership needed to change as much as the management resources in order to move the organization at hte pace required.
The obvious morale of the story: You can have too much management, if its not managing, leading and innovating. But you can easily have to little that will assure that you are ineffective in all of the above.
The thinking of the study authors that Paul Levy quotes is just that, that at a time with difficult challenges and cost or quality problems, is flattening the best solution. Might the situation need more managment and not less. Might the span of control lend itself to change better with greater hands on supervision and role modeling. Might the operating results be better in the short and long term by keeping good managment in place and seeking moe good management.
I have recently adviced clients that had alot of management to streamline. Why? Because the accountability was poorly defined, the roles were poorly defined and the managment culture was weak. They need more managment but not on top of what they had but instead of.
I had another client that was getting limited results from management. It was not because there were not enough, or that they were not competent, it was about the expectations and the QI processes in place to getthat team into a innovative mode. They were so bogged down by bureaucracy and history that they could not see their way out. Leadership needed to change as much as the management resources in order to move the organization at hte pace required.
The obvious morale of the story: You can have too much management, if its not managing, leading and innovating. But you can easily have to little that will assure that you are ineffective in all of the above.
Saturday, May 22, 2010
AHA new direction.....1944 ...not so far off
Interesting reprint in the AJN from 1944 on the "aims of the AHA". I wonder if the interest in covering everyone regardless of cost was the direct result of wanting to care for each other after the war. (More on that later). The one thing that is bothersome as you read this article is the mention of state planning commissions. Since the 1980s the push for competition has crippled planning. It seems almost counterintuitive today to promote state based planning. But also, it is a missing link until Boards really represent communities needs. (I think I wrote about this last year). I don't see the individual hospital's incentives changing enough to drive them to change. I see the disincentives may...
Wednesday, May 19, 2010
oil spills
I hate to ask. Not only am I related to an employee at BP (its the only thing Sarah Palin and I have in common) but I can barely watch the news on the Horizon oil spill. But it seems to me that there are lessons beyond BP and the oil industry. Why?
According to everyone I talk to at BP, "safety is the top priority". They keep hearing it over and over. Now, of course they had some high profile problems at Texas City (think the Duke medical center safety issue) that have caused multiple deaths and an inescapable need to take ownership for safety. So how did this happen if safety was the priority?
Can it be as simple as "show me the money" or testosterone as one 60 minutes interview suggested (I'm the boss was the example); it seems that efficiency and cost and timing issues (read cost) were weighing heavily on project that was taking too long. Or is it as we know in healthcare that the work of safety is never done. And people lose sight of the fact that the disasters are ever so overwhelming that they are rarely fixable. And the costs of a breech are enormous.
So are there lessons to be learned?
1. People at the sites seem to have had concerns that may have not triggered an automatic "abort" as is suggested in the military and aviation.
2. What are the adequate response mechanisms for disasters.
3. Should we be doing certain procedures or are they too risky.
4.What are the oversight/monitors on management
5. Have we codified procedures checklists and processes to the max?
6. What are the incentives for safety vs cost and efficiency.
7. And worst case, how well do we take responsibility and are transparent when we have a mishap.
We have learned these lessons before, have signed on to quality and safety, but are we moving to zero defects fast enough?.
I beg your pardon if I have stretched this to healthcare where it doesn't belong...but I am the wife of a BP employee...so everything is seen in the context of the spill. I think the spill has meaning to healthcare other than the fact that it finally got reform off the front pages of the paper and the cable news channels.
According to everyone I talk to at BP, "safety is the top priority". They keep hearing it over and over. Now, of course they had some high profile problems at Texas City (think the Duke medical center safety issue) that have caused multiple deaths and an inescapable need to take ownership for safety. So how did this happen if safety was the priority?
Can it be as simple as "show me the money" or testosterone as one 60 minutes interview suggested (I'm the boss was the example); it seems that efficiency and cost and timing issues (read cost) were weighing heavily on project that was taking too long. Or is it as we know in healthcare that the work of safety is never done. And people lose sight of the fact that the disasters are ever so overwhelming that they are rarely fixable. And the costs of a breech are enormous.
So are there lessons to be learned?
1. People at the sites seem to have had concerns that may have not triggered an automatic "abort" as is suggested in the military and aviation.
2. What are the adequate response mechanisms for disasters.
3. Should we be doing certain procedures or are they too risky.
4.What are the oversight/monitors on management
5. Have we codified procedures checklists and processes to the max?
6. What are the incentives for safety vs cost and efficiency.
7. And worst case, how well do we take responsibility and are transparent when we have a mishap.
We have learned these lessons before, have signed on to quality and safety, but are we moving to zero defects fast enough?.
I beg your pardon if I have stretched this to healthcare where it doesn't belong...but I am the wife of a BP employee...so everything is seen in the context of the spill. I think the spill has meaning to healthcare other than the fact that it finally got reform off the front pages of the paper and the cable news channels.
Quality of the Board
Okay, I am curious how much Boards are being prepared for the challenges of health reform. Besides an advocacy role trying to divert the worst from coming your way, there are a number of strategic issues that only the Board can wrestle. The question across the country these days is "How big is too big" but for healthcare, the question may be "how small is too small". For community hospitals or rural or even inner city hospitals, do you have the capacity to change. Do you have the size to restrict inpatient capacity in favor of outpatient and make the transition from current fee for service to bundled payments. How big do you need to be? How much competition will really matter in the future - can you be a one hospital town? Will the competition for beds be the issue or the competition on price and quality.
I'd say that the new guidelines in some states for formal Trustee education may be the opportunity not the threat. So the question of the day is how much should CEOs try to control or tailor their trustees education and how much should the Education become apart of the norm. Strategic systems thinking and the ability to be opportunitistic and evidence based in the near future could be a strategic advantage. We might start evaluating excellent hospitals on the quality of their boards not just their medical staffs.
I'd say that the new guidelines in some states for formal Trustee education may be the opportunity not the threat. So the question of the day is how much should CEOs try to control or tailor their trustees education and how much should the Education become apart of the norm. Strategic systems thinking and the ability to be opportunitistic and evidence based in the near future could be a strategic advantage. We might start evaluating excellent hospitals on the quality of their boards not just their medical staffs.
Tuesday, May 4, 2010
TMI....or too little?
As my daughter says with her fingers crossed in the shape of a T, TMI Mom! Translation: Too Much Information! As I read the breaking news, blogs, updates, mobile news services, paper management journals, it just feels like too much information - TMI, for gosh sakes! However the frustration is that it is really possibly too little information, alot of speculation and opinions and not refined, and defined adequately for action.
Busy executives need to understand, as do their boards, the actions that are coming around the bend and the actions that are part of a longer term plan. The reform agenda will roll out overtime but that does not mean that hospitals, doctors and healthplans can wait to see what emerges with a few brief comment periods.
This blog intends to breakdown the timelines and opportunities that doctors, hospitals and systems should be considering as the reform rolls out and to interpret some of the options.
TLGI. Too little good info is creating a combination of head in the sand and mistaken cues. There are finally some opportunites for good ideas to get funded but you have to be prepared.
Busy executives need to understand, as do their boards, the actions that are coming around the bend and the actions that are part of a longer term plan. The reform agenda will roll out overtime but that does not mean that hospitals, doctors and healthplans can wait to see what emerges with a few brief comment periods.
This blog intends to breakdown the timelines and opportunities that doctors, hospitals and systems should be considering as the reform rolls out and to interpret some of the options.
TLGI. Too little good info is creating a combination of head in the sand and mistaken cues. There are finally some opportunites for good ideas to get funded but you have to be prepared.
Wednesday, April 21, 2010
Prevention...
So what are you thinking about prevention? As an employer and potential employer of physicians, do you see the prevention side of this equation, now fully covered as an opportunity to be a win-win as an employer and provider? Are there opportunities to make it work in your favor? Clearly the returns are nothing like a hospital stay but does a hospital stay get you ahead of the curve.
Or take a lesson from education. Instead of cutting physical education at the Naperville public schools, some of the best in the country, the kids now have more opportunities to destress and get their brains oxygenated in the morning. Their results on tests and their performance overall improved. Is there an opportunity to "pay" employees to exercise during a free time or lunch time or before work? Would there be a savings in the long term in productivity, morale, retention and cost of insurance. Personal responsibility has not worked well in the past as the obesity rates climb. The carrot has always seemed negative to me - it looks like the stick.
How are you looking at your workforce - where are the incentives. Do your policies reinforce the healthy lifestyle that you are promoting to the public. Is the fryer still working overtime in the cafeteria? Are your employees wearing miniskirts and high heals or are they in running shoes able to sprint the stairs. What message are we giving the community with elevators full of unhealthy food and unhealthy staff.
Just thinking about prevention - and your most expensive resource - your people.
Or take a lesson from education. Instead of cutting physical education at the Naperville public schools, some of the best in the country, the kids now have more opportunities to destress and get their brains oxygenated in the morning. Their results on tests and their performance overall improved. Is there an opportunity to "pay" employees to exercise during a free time or lunch time or before work? Would there be a savings in the long term in productivity, morale, retention and cost of insurance. Personal responsibility has not worked well in the past as the obesity rates climb. The carrot has always seemed negative to me - it looks like the stick.
How are you looking at your workforce - where are the incentives. Do your policies reinforce the healthy lifestyle that you are promoting to the public. Is the fryer still working overtime in the cafeteria? Are your employees wearing miniskirts and high heals or are they in running shoes able to sprint the stairs. What message are we giving the community with elevators full of unhealthy food and unhealthy staff.
Just thinking about prevention - and your most expensive resource - your people.
Thursday, April 8, 2010
Are you between reform and your board?
It seems to me that more and more CEOs have woken up to realize that with the Health Reform package not only is their business model heading toward a fairly major change in a relatively short time (more change than DRGs which felt like a tsunami at the time), but that they are being criticized for going along with it. The fact that every major healthcare organization (trade association, professional association etc) advocated for it puts the CEO in a difficult spot. With subspecialists that do not want a change in a career and income path that they "sacrificed" alot for ( and worked 25 years for), meshed with somewhat conservative business and community leaders heading up boards, you can feel the squeeze.
Phones are ringing. Voices raised. Emotions all over the place. One leader said, "I know now why no one took this on in years past!". What is one to do?.....
It seems to me that there is an opportunity to provide consumer ready copy for distribution by healthcare institutional leaders to help people understand the unique positives of this plan and the opportunities for the organizaiton, doctors and community. And the hospitals need some help identifying the paradigm shift and how to mitigate the negatives while dealing with change. No one wants to change, especially if you are in the minority that benefits. (Ask White South Africans about change...its scary but it is also inevitable). There is an opportunity for us to support leaders as they support terrified constituents face a new future. It is not fair to let these folks figure it out themselves...they invested in the status quo in good faith...so let's stop labeling and start planning how to make the future work...starting in the present.
Phones are ringing. Voices raised. Emotions all over the place. One leader said, "I know now why no one took this on in years past!". What is one to do?.....
It seems to me that there is an opportunity to provide consumer ready copy for distribution by healthcare institutional leaders to help people understand the unique positives of this plan and the opportunities for the organizaiton, doctors and community. And the hospitals need some help identifying the paradigm shift and how to mitigate the negatives while dealing with change. No one wants to change, especially if you are in the minority that benefits. (Ask White South Africans about change...its scary but it is also inevitable). There is an opportunity for us to support leaders as they support terrified constituents face a new future. It is not fair to let these folks figure it out themselves...they invested in the status quo in good faith...so let's stop labeling and start planning how to make the future work...starting in the present.
Monday, April 5, 2010
Is there a take-away here?
The headline read "WellPoint CEO Braly received a 51 percent compensation boost in 2009". Okay so she worked really hard and she got a great deal in health reform requiring everyone to essentially buy insurance and the public thinks they didn't get what they want. So its a win-win....for her. But where did WellPoint miss the fact that the insurance companies were called "greedy" and uncaring and unethical - essentially all in the name of profit! How do you structure compensation in this environment to total $13 million when your rates are escalating by almost 40% for some of the insured. I say that that multiple of salary from the lowest paid worker or the average family in the US to $13 million is beyond arrogant and "capitalistic". It doesn't pass anyone's reasonableness test for what is fast becoming a public utility and it looks like a complete lack of fiduciary oversight in this market and a slap in the face of the public.
Okay, I get that it is hard to be an executive of a huge company; that you make sacrifices including never seeing your family; that your competitors are paying ridiculous sums and yes, that she is a woman and if its good enough for men all these years she ought to get the same private equity stock.
But put all that aside for a minute. Do the same rules of the 1990s, and early 2000s apply here at all? Did we not just see a recession where retirements were lost or delayed, where houses were lost and safety nets failed and many more people joined the ranks of the "uninsured" in healthcare. None except the most minute segment of society are secure in their financial futures. The economy isn't recovering fast because of fear. So in this environment, a board would payout a compensation package that is mind-boggling to even more than the average American.
My thought here is that the healthcare industry including and most importantly the not-for-profit sector (hospitals) better start to think differently about compensation going forward. Not necessarily the small hospital in a rural location whose VPs just barely make six figures but the escalating salaries and bonuses for the top brass. The incentives better be more obvious to the consumer of health than the Well point package is. The value added to the community and each patient ought to be clear in the compensation since each of those customers is paying for the product. And Boards better start to question the standard that they are using....or Senator Grassley will for you!
Okay, I get that it is hard to be an executive of a huge company; that you make sacrifices including never seeing your family; that your competitors are paying ridiculous sums and yes, that she is a woman and if its good enough for men all these years she ought to get the same private equity stock.
But put all that aside for a minute. Do the same rules of the 1990s, and early 2000s apply here at all? Did we not just see a recession where retirements were lost or delayed, where houses were lost and safety nets failed and many more people joined the ranks of the "uninsured" in healthcare. None except the most minute segment of society are secure in their financial futures. The economy isn't recovering fast because of fear. So in this environment, a board would payout a compensation package that is mind-boggling to even more than the average American.
My thought here is that the healthcare industry including and most importantly the not-for-profit sector (hospitals) better start to think differently about compensation going forward. Not necessarily the small hospital in a rural location whose VPs just barely make six figures but the escalating salaries and bonuses for the top brass. The incentives better be more obvious to the consumer of health than the Well point package is. The value added to the community and each patient ought to be clear in the compensation since each of those customers is paying for the product. And Boards better start to question the standard that they are using....or Senator Grassley will for you!
Wednesday, March 31, 2010
She must have run hospitals in her early career!
"Look at a day when you are supremely satisfied at the end. It's not a day when you lounge around doing nothing; it's when you've had everything to do, and you've done it."
Margaret Thatcher
Margaret Thatcher
Friday, March 26, 2010
Reform and hospitals
Reform means that everyone has skin in the game, individuals, employers, states, the federal government and insurance companies. They are now the new "consumers" of healthcare. And it will be confusing to all of them as they figure it out. So what will they look for: the best value for their dollar. How they define value will change by constituent, by age demographic, by plan. What they will all have in common is an overwhelming interest in the cost! They collectively will never pay on the curve we are going on in healthcare delivery.
So what do hospitals need to do:
1. Help define the measurement of value: quality, quantity and cost. Outcome data will be key but preventive services, highest quality physicians, and cost will be the test.
2. Integration: delivery from one provider and service to another must be more consumer friendly. That includes all processes.
3. Information: consumers want it. They want their own info and they want info to compare theirs to.
4. Appropriateness: redefining community standards of care. Do you substitute great nursing and customer service for expensive testing that doesn't add value?
5. Understanding personalized care and getting on top of it before it becomes a costly necessity. Collaborative approaches to moving genomics into the delivery setting to eliminate wasteful treatments that don't improve outcomes.
That's just the beginning....
P.S. Do you jump on number one by being the community resources that explains to citizens how this affects them and how they should start looking at their healthcare dollar?
So what do hospitals need to do:
1. Help define the measurement of value: quality, quantity and cost. Outcome data will be key but preventive services, highest quality physicians, and cost will be the test.
2. Integration: delivery from one provider and service to another must be more consumer friendly. That includes all processes.
3. Information: consumers want it. They want their own info and they want info to compare theirs to.
4. Appropriateness: redefining community standards of care. Do you substitute great nursing and customer service for expensive testing that doesn't add value?
5. Understanding personalized care and getting on top of it before it becomes a costly necessity. Collaborative approaches to moving genomics into the delivery setting to eliminate wasteful treatments that don't improve outcomes.
That's just the beginning....
P.S. Do you jump on number one by being the community resources that explains to citizens how this affects them and how they should start looking at their healthcare dollar?
Tuesday, March 23, 2010
Wow. Its signed.
I understand the concerns over the government doing anything given the fact that I am a resident of Illinois. But this is one of the few things in life where the government should be in. So I am glad that we have started today. Why?
1. The market didn't work to solve the issue of the uninsured. It is not a market anyone wants. People who are only buying what they need when they need it and because of poverty and lifestyle could actually be a bad risk (and then you have to cut them off). I ran an inner-city hospital and I can assure you that on the day we would have closed that place, no free market would have rushed in. The other struggling hospitals would have picked up the few patients on which they could make an incremental margin. THERE IS NO MARKET FOR SICK PEOPLE WITHOUT RESOURCES.
2. The system is not a system, is not a system. It is very fragmented and gamed for where the revenue comes from. It has to work that way to make up for the unbelievable fragmentation and cost-shifting. Everyone clips toenails if that is what is paid for. Every one does detox if it pays. And if you are fortunate to be in an insured market where Orthopedics, Cancer and Neuroscience pays then you look like you don't game the system. Will this be solved with reform? Not in the short term but as insurers have to take on everybody, their skin will be in the game too.
3. There is no ability to group purchase without a large entity. Even the government doesn't group purchase pharmaceuticals to the extent that the insurers do. Medicare is much more generous then my group insurance because of the politics of Medicare.
4. Medicare will go broke at the current rate (because it is an isolated political block and can't be touched as it is now) and Medicaid which is a burden on states will go broke with the extra burden of an out of control system. Some large structure has to create the moment for systemic, not piecemeal change.
5. "Managed care" needs to reemerge under the pay for performance and system incentives that are developing. The old managed care where specialized nurses managed your CHF, Coumidin and other chronic diseases and medications over the phone or computer line to keep you well and out of the ER.
6. 40% profit margin on certain lines of business that only cover the elite among us are not a sustainable model for cost control and access. The new administrative cost caps are still very generous.
Unfortunately my taxes will go up, right as my kids head toward college. I guess that means alot of change for my family who is lucky to be college-bound and insured. We are also lucky to be in America. We are also lucky that our health insurance can't cut us off for preexisting conditions now. I'm not able to say the same for my life insurance which I lost with a job change and won't be seeing again.
1. The market didn't work to solve the issue of the uninsured. It is not a market anyone wants. People who are only buying what they need when they need it and because of poverty and lifestyle could actually be a bad risk (and then you have to cut them off). I ran an inner-city hospital and I can assure you that on the day we would have closed that place, no free market would have rushed in. The other struggling hospitals would have picked up the few patients on which they could make an incremental margin. THERE IS NO MARKET FOR SICK PEOPLE WITHOUT RESOURCES.
2. The system is not a system, is not a system. It is very fragmented and gamed for where the revenue comes from. It has to work that way to make up for the unbelievable fragmentation and cost-shifting. Everyone clips toenails if that is what is paid for. Every one does detox if it pays. And if you are fortunate to be in an insured market where Orthopedics, Cancer and Neuroscience pays then you look like you don't game the system. Will this be solved with reform? Not in the short term but as insurers have to take on everybody, their skin will be in the game too.
3. There is no ability to group purchase without a large entity. Even the government doesn't group purchase pharmaceuticals to the extent that the insurers do. Medicare is much more generous then my group insurance because of the politics of Medicare.
4. Medicare will go broke at the current rate (because it is an isolated political block and can't be touched as it is now) and Medicaid which is a burden on states will go broke with the extra burden of an out of control system. Some large structure has to create the moment for systemic, not piecemeal change.
5. "Managed care" needs to reemerge under the pay for performance and system incentives that are developing. The old managed care where specialized nurses managed your CHF, Coumidin and other chronic diseases and medications over the phone or computer line to keep you well and out of the ER.
6. 40% profit margin on certain lines of business that only cover the elite among us are not a sustainable model for cost control and access. The new administrative cost caps are still very generous.
Unfortunately my taxes will go up, right as my kids head toward college. I guess that means alot of change for my family who is lucky to be college-bound and insured. We are also lucky to be in America. We are also lucky that our health insurance can't cut us off for preexisting conditions now. I'm not able to say the same for my life insurance which I lost with a job change and won't be seeing again.
Friday, March 19, 2010
Execution
Can the Democrats deliver? If so, what is it going to mean to your organization? Execution on a number of projects, on a number of sacred cows, on a number of system changes, on physician alignment, on incentive plans. Where will your focus be? How to focus your team on change? How to move out of your comfort zone?
When the spotlight switches from Congress to the Insurance Companies and exchanges....how will healthcare providers get moving for the moment, soon when the spotlight turns solely on you?
When the spotlight switches from Congress to the Insurance Companies and exchanges....how will healthcare providers get moving for the moment, soon when the spotlight turns solely on you?
Tuesday, March 16, 2010
Down to the wire.....is it a costly mess or a new start.....
Check out the Health Affairs latest blog on why it needs to pass!
http://healthaffairs.org/blog/2010/03/16/a-consumers-advocacy-group-refutes-the-anti-health-reform-myths/
http://healthaffairs.org/blog/2010/03/16/a-consumers-advocacy-group-refutes-the-anti-health-reform-myths/
Physicians needing a bailout?
Specialty vs. Primary Care. The Pendulum swings again. Specialists (Cardiology this time) take a deep cut from Medicare, one many thought they would avoid and are still lobbying againgst. So deep that many are asking for...a what...say that again....a bailout? A government bailout? No a hospital bailout!
The argument goes like this: as a cardiologist I don't make my $400k per year salary until after I am 33 years old. I work 80 hour weeks and save lives. That's only $200/hour (something no self respecting management consultant would accept!). And if you take into account the 10 years that you didn't get paid....okay I get it. No please don't take a pay cut! Bail them out!
Last time I looked, in most major metropolitan cities cardiologists were a dime a dozen. If you ask them about testing, those that have the tests available say that they probably test more than they need to because its there and if they are in a hospital without cardiac cath, god forbid, they actually do slightly less testing than average. My point, their competition is not increasing quality and decreasing price, it is actually increasing overall cost.
A 25-30% cut means a major change for these practices - fixed overhead, "fixed" salaries (why should they take a salary cut if the bankers didn't!). So what is a practice to do? Let some folks go! Restructure to provide only the services most needed? Spend more time with patients? Pay your diagnosticians the highest salaries? Manage your patients computerized record and make adjustment to keep them well and away from expensive tests? Bring in Cardiac and Geriatric Nurse Practitioners? Focus on rehab?
The head of the Association of Family Practice Physicians had little sympathy for the Cardiologists as she sees the shift in their payment going to her colleagues. Stating that the discrepancy between salaries is a factor of 4, she essentially told them to get a life!
P.S. Community based medical staff planning is different from hospital based medical staff planning. Executives should be doing both or they will be left with alot of expensively bailed out specialists and some underused capacity when bundled payments begin.
The argument goes like this: as a cardiologist I don't make my $400k per year salary until after I am 33 years old. I work 80 hour weeks and save lives. That's only $200/hour (something no self respecting management consultant would accept!). And if you take into account the 10 years that you didn't get paid....okay I get it. No please don't take a pay cut! Bail them out!
Last time I looked, in most major metropolitan cities cardiologists were a dime a dozen. If you ask them about testing, those that have the tests available say that they probably test more than they need to because its there and if they are in a hospital without cardiac cath, god forbid, they actually do slightly less testing than average. My point, their competition is not increasing quality and decreasing price, it is actually increasing overall cost.
A 25-30% cut means a major change for these practices - fixed overhead, "fixed" salaries (why should they take a salary cut if the bankers didn't!). So what is a practice to do? Let some folks go! Restructure to provide only the services most needed? Spend more time with patients? Pay your diagnosticians the highest salaries? Manage your patients computerized record and make adjustment to keep them well and away from expensive tests? Bring in Cardiac and Geriatric Nurse Practitioners? Focus on rehab?
The head of the Association of Family Practice Physicians had little sympathy for the Cardiologists as she sees the shift in their payment going to her colleagues. Stating that the discrepancy between salaries is a factor of 4, she essentially told them to get a life!
P.S. Community based medical staff planning is different from hospital based medical staff planning. Executives should be doing both or they will be left with alot of expensively bailed out specialists and some underused capacity when bundled payments begin.
What if you stop trying to fill beds?
Does your hospital have a horrible problem of patients waiting for a bed and can't get an imaging test and your staff is managing utilization to accomodate patients! Oh, you lucky one! All you think about is how to get patients to outpatient care! Hopefully you aren't adding beds! I suspect that you are the fortunate minority well financed, full, good reputation.
That is all well and good but what if you are the hospital with the 6% volume drop, the beds are not full and your entire focus in on filling them, courting doctors etc. I suspect that there is a good majority of hospitals in this category and they are creating strategies to boost their relationship with physicians and advertising their centers of excellence in OB and cardiac.
What if we stopped filling beds? Okay okay, I know that all your significant revenue is tied up there but that could change. Maybe just maybe you could be a different looking organization? Do you have the cash to transition? What are the options? What is coming down the road in terms of change that you could put your effort into? What is poorly reimbursed that makes more sense than what you are now doing that you should be advocating for? Are you too small to transition to accountable care? Or so large that it takes a tsunami to move you in a different direction? Do you really add value to the community and if so, how? Can you leverage the areas where you add value in a different way - specialty center part of a larger organization, for example?
Is this the conversation your board is having? If not, you might want to move in that direction. Its got to be more pleasant than be questioned about volume!
That is all well and good but what if you are the hospital with the 6% volume drop, the beds are not full and your entire focus in on filling them, courting doctors etc. I suspect that there is a good majority of hospitals in this category and they are creating strategies to boost their relationship with physicians and advertising their centers of excellence in OB and cardiac.
What if we stopped filling beds? Okay okay, I know that all your significant revenue is tied up there but that could change. Maybe just maybe you could be a different looking organization? Do you have the cash to transition? What are the options? What is coming down the road in terms of change that you could put your effort into? What is poorly reimbursed that makes more sense than what you are now doing that you should be advocating for? Are you too small to transition to accountable care? Or so large that it takes a tsunami to move you in a different direction? Do you really add value to the community and if so, how? Can you leverage the areas where you add value in a different way - specialty center part of a larger organization, for example?
Is this the conversation your board is having? If not, you might want to move in that direction. Its got to be more pleasant than be questioned about volume!
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