Lessons learned in 2011

Its that time of year again! And this one ends on a bang....so much going on and so much anticipation.

So in reflecting on the year what did we learn.

• "The cats out of the bag". Even if the supreme court reviews the individual mandate, the hospital industry is irreversibly changed. Consolidations were never more robust than this year. Everyone is looking for a partner. And those that aren't, may be coming to the table too late. So with or without the mandate, reform is coming to the hospital business.
• Care can be managed. This is not the HMO of the 1980s or the Aravind hospitals in India that have 4000 beds for eye care but it can be more productive and expertise consolidated. Evidence based medicine, outlier management, and social support work.
• Symptoms of chronic disease can be managed by physician extenders and nurses. Warfarin (coumidin) is frequently managed tightly not by primary care or cardiologist but by a "clinic" of nurses.
• Protocols work to manage potential readmissions. (Frail elderly etc).
• Even one visit to a social worker makes a statistically significant difference in compliance in most vulnerable cancer patient populations. That is an inexpensive option to keep expense equipment and staff fully functional and productive and to have better patient outcomes.
• The EMR is only as good as the process of inputting data. One early adaptor experienced 30% vacant fields in conducting clinical research by having an "unknown" or "other" option.
• FQHC's have alot to share in terms of care management practices. Their challenge will be whether they are are the dog or the tail in controlling care management dollars.
• Boards that revise their own process including transparancy, quality and executive sessions as critical components of their work will get the most out of management and medical staffs. CEOs that can manage transparency have a future!
• Boards that include strong (not marginalized) patient and community voices among their members will begin to see a transformation from "corporate" to "community benefit". Listening to patients in and of itself is a significantly new function in hospitals. Patients for the past 20 years have complained that it doesn't matter how often its explained to them, they don't understand why certain things don't work to their perceived benefit. That data is very valuable if used.
• Clear accountability structures for management and having the right people on the bus is critical. The right people might still need mentoring/coaching as the paradigm shifts.
• An objective strategist who will provide direct input and challenge the status quo is critical for all executives. Find the mentor, colleague or coach that will do that. The stress level has escalated so much that leaders need objective support on their team.

I learn more and more from the clients and colleagues with whom I work. The biggest lesson is always how a single minded dedication to quality, with a sense of humor and respect for coworkers is a key to amazing accomplishment.

Predictions for 2012 will be coming soon!

Occupy Wall Street: Occupy Healthcare?

Where does healthcare fit in with the anger of the OWS crowd.  In short, it seems to be a group of mostly young/younger folks who are discouraged (angry) at not only the enormous wealth redistribution of the last 30 years but the enormous power redistribution of the last 10-15 years.  Clearly, individual access to their government is nonexistent without a fee.  The only individual interaction with government for most of these people is unpleasant - IRS issues, immigration issues, tickets, fees and regulations.  What was good with the financial industry, helping move middle class people toward retirement, or loans to keep a business afloat is mostly non-existent these days.  What was good with government, support of science, advances in technology that could be rolled into drivers in the private economy, strong infrastructure, reasonably priced transportation and education is now also a thing of the past.

So does this have anything to do with healthcare or have we already been under the microscope and had our reality check.  Hospitals and doctors have heard that it costs too much and that the industry has self corrected so slowly that the government is stepping in to create the incentives and the hammers.  But have we really had our occupy moment?

Let's consider the trends.  "Size and scale are essential."  "Consolidation, mergers and closures will only increase."  "Systems are national and regional".  With systems, often goes the elimination of the community board.  National trends are driving toward fewer independent players and we are seeing hospitals serving regional, national and international markets.  Charity care is being measured and with it, tax exemption.  Threats to no longer serve certain product lines if tax exemption goes away are discussed behind closed doors.  Margin drives product line development, not community need.  Competition raises costs in many markets.  Patients have limited rights over their own records (think credit companies).

The public sees physicians seeking higher incomes (rightly so given the right to passage in medical school is a $200-400k investment).  CEOs average income is $750k with a range that seems to have a bottom but no ceiling.  Health insurers are in the banker category. Clearly the 1%.

Health disparities are rising along income and racial lines.  Blacks and Latinos are being hit with the highest unemployment and already experienced documented outcomes that were far worse than the average population.  Twenty two percent of children living in poverty, translating into a large segment of the population that get their health care from doctors that accept Medicaid.  Many don't or don't practice in an area where the poor live.

Are we immune from the anger?.  I think not. It has always been there through the tort system but that was a small percent.  The 99% is realizing that it can't access healthcare, can't pay for it and can't always influence how it is delivered in its community.  Loss of control, yes.  Anger, could be.  I don't think its going away.

Whoa....25% of leaders are not engaged in changing the model of care....heading to the clash of cultures!

Fierce Healthcare reports:  "While accountable care organization (ACO) Pioneers are set to launch before the year's end, a recent report indicates that many hospital executives remain unaware of the federal regulations needed to become an ACO.

According to a survey of more than 200 provider organizations, it is most often the hospital CEO who is responsible for ACO development, yet only 15 percent of hospital executives said they were "very familiar" with ACOs as currently proposed; 25 percent were "not familiar" with them, at all.

The survey, conducted by consulting firm Beacon Partners, also found that almost half of hospital execs (48 percent) don't know how an ACO will impact their organization, or whether it will improve patient care.

Despite the unfamiliarity, 92 percent of respondents already are in the planning/development phases of an ACO, with 30 percent in the operational phase.

Half of the responding organizations (53 percent) have yet to create a department or executive position dedicated to ACO development, and only 10 percent plan to hire additional staff to implement ACOs, leading the survey authors to question whether the healthcare sector will be fully prepared for reform."

It is terrifying that the deficit is creating the norm in Washington that spending will be reigned in and half the CEOs in the US are somewhat to absolutely clueless about how they can move their organization to a sustainable rate of return based on changing the norms of care.  The CEO is the most important player in moving an organization to focus on the need to decrease the cost of traditional care by substituting less costly outpatient and preventive care at a lower rate of reimbursement.  The CEO needs to understand that the reimbursement paradigm is so different and a transition must occur to assure that the organization is positioned to fully deliver in the future.

Letter to the Editor

I read the article in Tuesday's Wall Street Journal on Patient Navigation with interest.  But more interesting were the slew of negative comments about "added" or "unnecessary" expense of the navigator.  I was compelled to write a letter to the editor (which will not be published most probably) so I am sharing some thoughts via the blog!

Only someone who has luckily never had a chronic disease or a surgery would suggest that the Doctor was all you need to manage your healthcare experience and your healthcare outcomes.  Navigation is fast becoming the norm.And a necessity.

What is navigation?  It is the support and coordination that most patients need to understand and make the most of the care available to them.  Usually provided after an assessment by a social worker or nurse, it can range from something as simple as directions and a parking voucher, to accessing wigs, interceding with employers, explaining the appointment system, arranging transportation or housing to deciding on participating in a clinical trial.  Most patients and families in these complex and costly treatment cycles need support and navigation is there to provide whatever support will facilitate care.

Navigators do not replace clinical teams.  They are part of the team.  They support and reinforce patient education.  They arrange support groups.  They open doors.  They do not diagnose, or determine treatment options.

This is an expense that makes a difference both in lives and in overall cost of care. 

Our study of navigation among different ethnic groups who historically have had disparate care, showed a significant improvement in the compliance with care regimens for late stage high risk patients.  In addition, for those patients with Medicaid or no insurance, navigation made a significant difference before and after navigation in the patients ability to access care in a timely and cost effective manner.  Compliance saves lives and navigation improves compliance.  Its that simple.

Obamacare: Why are the deficit hawks not for it?

 From 2000 through 2009, Medicare’s outlays climbed by an average of 9.7 percent a year. By contrast, since the beginning of 2010, Medicare spending has been rising by less than 4 percent a year. On this,  both Standard Poor’s Index Committee and the Congressional Budget Office (CBO) agree.

Why are we not hearing that indeed the cost curve is bending.  The objective of the Affordable Care Act is to expand care to the uninsured and to make sure that those that need care are getting care that is of high quality and affordable (the value proposition!).  So why when the healthcare industry, especially providers, are beginning to put in place, often to their own short term disadvantage, changes in practice that save money, does the Act still have a bull's eye on it?

When you start talking about cutting entitlements when there are ways to save billions annually right in front of us is surprising and seemingly not in the best interest of anyone.  The only thing that makes sense to me is that it is a sound bite that is so simplistic (government is the boogyman) that the political appeal is too much to resist.  Because from a practical sense, there is not a tea partier alive that resides in Vermont or New Jersey that wants FEMA and disaster area funds cut.

In the twelve months ending in May, overall spending by commercial health insurers climbed by 7.35 percent. By contrast, over the same span, Medicare claims rose at an annual rate of just 2.6 percent.(S&P and Congressional Budget Office)


So why do we think that the government cannot manage this huge national problem?  The facts just don't add up to support privatization.

Here are a few of the programs that have proven that expenditures can be reduced and not only not reduce quality but actually improve it (From Healthcare.gov

Proven Results with Bundled Payments
Both Medicare and private health care providers have shown that bundling payments improves care for patients, and leads to better health, better care and lower costs. 

• During the five-year Heart Bypass Center Demonstration (started in 1986) Medicare saved $42.5 million – or 10 percent – on Coronary Artery Bypass Graft surgery at participating hospitals  in Atlanta, Columbus, Ann Arbor (Michigan), and Boston, largely through improved hospital processes and a reduced need for intensive care.  Medicare patients saved $7.9 million in coinsurance payments.
• Medicare’s three-year cataract surgery demonstration (started in 1993) was also successful in reducing Medicare spending by $500,000 for approximately 7,000 procedures at sites in Cleveland, Dallas/Fort Worth, and Phoenix.
• The fixed price for Coronary Artery Bypass Grafts (CABG) under Geisinger’s ProvenCare reduced costs and improved patient care showing that hospital costs dropped 5 percent, average length of stay fell by 0.5 days, and the 30-day readmission rate fell 44 percent over 18 months for Pennsylvania hospitals in Geisinger’s network.

These are real results that can attack the out of control costs by creating systemic change - not by denying care.  As the old song goes,  "all we are saying, is give (peace) a chance"  - I think its time to give the Affordable Care Act a chance.  This program deserves the support it needs to assure that no one is going to go bankrupt after an unnecessarily long hospital stay!

Hope for the future!

I want to give a huge shout out to the kids from the Latin School in Chicago who at their own expense (and actually after raising $20k), set off to Kigali Rwanda for the second year in a row to give HIV infected teens a chance at some real fun.  It is a place of acceptance and sacrifice and these kids have given it their all.  The country is beautiful and troubled.  It has a legacy not too be envied and a future that could be powerful with the help and confidence of this generation and the adults who led their way.  Pictured above is my daughter Lizzy who braved the trip last year and helped make sure it happened again. Her friendships are international and eternal.  Go girl!

It is really not the same

I had breakfast with a very wise (but not old) colleague yesterday who shared her belief that we need a new brand of leadership to right this ship and move it to the next level.  No, I am not talking about Washington DC (no matter how relevant that might be), I am referring to our healthcare leadership.

We have wonderful leaders and managers in healthcare - especially hospitals and especially hospitals with adequate resources.  They manage their bounty well and create additional income.  That is what we have always wanted of healthcare management and that is how we have measured them.

Unfortunately, we are at a crossroads where that is no longer enough...not that creating a surplus and adding value isn't enough, but at this juncture, it is not what it will take to succeed.

What will it take to lead in the years 2012-2020?  First, I believe it will take profound creativity and vision - to step back from the success of the past and to look at it under a very powerful microscope.  In doing so, some of those metrics might not lead to where we need to be.  Secondly, it will take single-minded dedication to a change in course, no matter what the intermittent stumbling blocks and short term losses are. Third, it will demand more participative, cooperative relationships - driven not by what the institutional needs are but what the patient and providers will need to be more efficient.  That third point, requires a suspension of ego and status, an ability to bury the images and baggage of the past to define a new system.  Fourth, it requires system thinking.  Each process in the system needs to be able to communicate and mesh with other processes but they need to be clear and safe.  Which means complexity needs to be routed out of the system instead of embedded in it.  Fifth, it requires absolute transparency.  A problem is a problem and a solution is only a solution if it drives to the outcome intended.

Do we have leadership like this in healthcare?.  Absolutely.  Is it universal? Not even close.  What we used to say about raising kids is that they are the most dangerous when they don't know what they don't know.  I think we are right at that point.  A lot of teenagers who know they know ---but just maybe we don't see what we need to see to move forward.  It is going to take some growing up (and I don't mean eat your peas) to hear what patients and doctors and nurses have been saying all along.  The system is broken in that it delivers excellent care but not excellent outcomes.  At this cost, we will need to look more closely and listen very carefully to identify what the population we serve needs to stay out of our institutions.

How do you embrace change if you can't see it?  I have always believed that there are two drivers: cost and patients.  If you want to lessen your own cost in your own institution, forget it.  All you do is trim the edges.  If you want to reduce or bend the cost curve, then you can begin to see the changes.  You can see that it is not this one patient's stay but maybe a whole category of the most expensive medicare patients that all have 4 or 5 variables

Murdoch and lessons for leaders

Obviously, there are probably thousands of lessons to be learned from studying Rupert Murdoch's rise to wealth and some say too much power.  But watching his testimony yesterday before parliament, I was reminded such an extraordinary man either rose to power unethically or he had his head in the sand much of the time.  I don't believe we want to focus on the ethical issues although with power comes an arrogance that leads to potential corruption.  While his apologies were very contrite and sincere on face value, the damage done by weak, ineffective and/or arrogant management makes the apologies seem quite a little too late.

How many boards and managers have been caught unaware of a serious issue and believed passionately that they were the one to fix it.  Maybe once but not twice.  As Murdoch was asked why he was not resigning and he said that he was the best person to lead them out of this mess, I was assured that he believed it, but from my seat, I did not.  How can you turn your back, ignore or just plain miss illegal processes going on under your nose, granted under several noses down the chain, and think that you will spot the next big thing.

Management is always about cleaning up messes and addressing problems but when management's approach allows those messes to happen, those processes to break over and over, why do we want those same people to fix them.  And why do we want their fix anyway.

Unfortunately, in the healthcare world this is also the case.  Well intended folks relying on people they "trust" to do the right thing.  I sure would not want to get on a plan that was operated on trust.  And frankly our communities and our patients don't want to get their healthcare in such places either.

I see this in not-for-profit organizations all the time where the effort to lead is rewarded as well as the actual successful act of leading.  And too often others are hurt in the mess.

Good management, rests on more than those you trust.  Of course, it is sure nice to have a few of them around but even they need to be held to a transparent standard of performance.  If the performance looks too good to be true, it probably is.  Instead of enjoying it, look into it next time.

Women leaders...what we know!

The takeaways from the Modern Healthcare's 1st Annual Conference celebrating the top 25 female healthcare leaders were numerous and summed up beautifully by the Chief Transformation Officer from Piedmont Health another sponsor.  To name a few:  culture as we all know is incredibly difficult to change and cultural language in describing women is one of the first areas that needs to change.  Gail Evans, noted author among other amazing career heights, shared her research on how men are described in references and how women are described.  She hilariously pointed out the "drudgery" descriptions of women - dedicated, loyal, hard working, smart.....all the characteristics that you want in your middle management ranks.  But when it comes to men, they are described by both women and men as "having leadership potential, strategic and can close the deal".  These are the guys that are going to get the job.  So before you give another recommendation for your women colleagues and friends, think before your speak and make sure she "is a leader, drives results, is strategic".

And while we are on the subject, how many women are you recommending for boards, jobs and awards?  It seems too few.  According to Evans and others on the panel, you need 3 women on a board or in senior management to feel the impact.  One is where we are now (and we all know how that feels), two makes it hard to disagree with each other, but three allows the individuals strengths and power to have their full impact.

There were several powerful exceptions to the woman leadership style that says that "I couldn't have done it without everyone else".  These women clearly made the point that everyone else might not have gotten it done without them.  We don't need ego but we do need to share the powerful message that each of these leaders is making a significant contribution.  That's when we will feel the impact on the next generation of leaders of "Chicks in Charge"!

If appropriate compliance saves money....

then patient advocates or navigators are a sound investment.  For patients that we studied among three academic medical centers the patients with the most severe cancer and the most hurdles socio-economically (mostly uninsured) had equal compliance with others after navigation.  However, they never caught up to the commercially insured and earlier caught cancer patients who received social and nutrition, advanced nursing or clinical trial support at the most resource intense hospital. 

But what this means is even one social worker intervening at a few key points can make the difference between receiving a full course of radiation therapy or not.  When you are trying to cut through the weeds of health reform, some of the most basic things make the most sense.  Compared to the cost of having a radiation therapy suite sitting idle because of a missed appointment and the potential additional therapy, the cost of a social worker seems to make alot of sense.

But what we cannot lose from this study to be shared in the ASCO proceedings of their recent meeting in Chicago is that lack of insurance, being of color and being poor are the primary determinants of health outcomes today in this country, as amazing as that is.  Poor insurance is no panacea and does not assure access.  Medicaid patients faired better than uninsured but still less well than their more well off brethren.

Should patients ask doctors for references?

Can you imagine the reaction of most doctors if you asked for a reference?  I would be a little scared that I would be asked to leave the office by the most secure among them.  I might get a befuddled reference to privacy by the most aiming-to-please types.  I don't think they would laugh.  And I don't think I would get one.

But why not?  I get references on everyone.  Not just referrals from the neighbor or friend, but references.  I check them out.  I check out lawyers - look at their reputation.  Definitely whether they have won this type of case before I give it to them.

Clearly for employees of all types references are essential.  And in positions of authority where critical thinking skills and judgment are required, many references are checked.

We have come of age in an era where the medical staff at the hospital was "delegated" the reference checking function for all the patients.  Who better to look at the record of another doctor than another doctor.  But why, in this era of managed care, accountable care, consumer driven care, value based purchasing, do we not think that consumers of care (formerly known as patients) should ask for and check references.

So who would those references be?  They could be voluntary patients who want to comment on the equivalent of the big "Angie's List"  of doctors on the internet, it could be a letter of reference from some of the rating agencies, or better yet it could be from the emergency room physicians and nurses that see too many repeat falls from a practice or perfectly managed CHF patients who rarely come in more than once or other indicators of overall practice performance.  It could be pharmacists that routinely have to stop and call on prescriptions because of drug interactions or a home health nurse that finds the physician to be the most cooperative in terms of getting needed therapies for in-home elderly.

And yes it could be the patient who can tell you that his last physician missed diagnosed his CHF three times before he changed to this new, and excellent primary care physician!

Can you really imagine getting up the nerve to ask that surgeon for references?

I hope this is not your approach to Accountable Care...

This struck me as hilarious.  I am not sure why.  Maybe because for some it is so far from the truth but for others it just might be spot on.  The you tube animation is classic "overwhelmed but got to have a plan".  So enjoy http://www.youtube.com/watch?v=lF8bK7AJyL0

If by chance you find that you are relating it might be time to talk to someone about how you focus attention on this effort or avoid it altogether.  If you were to do so you would not be alone.  The majority of a recent survey are ignoring ACOs. 

If however you think that there is potential in your market or an imperative in your business model to change, then its time to find an expert to help guide you, in your own learning curve, in building this model.

Separate but unequal?

The Kaiser Health News reported that the uninsured were significantly less satisfied with their care, both in terms of quality and cost. Is this important news?  We have always seen care for the uninsured as a cost issue and an access issue, but have not discussed adequately "access to what?".  Health disparity data are one alarming measure, getting increasing study but relatively few fixes.  Does this says to those who have cared for the uninsured, that they do not have access to quality care.  Is this a wake up call to those providers or is it a wakeup call that there are not the same resources going into their care, and the poor know it.  I have always speculated that one of the reasons that the insured are increasingly against health reform, or government sponsored care, is because they are afraid not that it would become more expensive or bureaucratic but that they would receive the quality of care that the uninsured receive now.  A potentially dummied down version of care and services with the barriers that so confound the poor.  The red tape, the lines to wait in to get medicine, the decisions to sit in waiting rooms because at least they will get seen and tested that day.  We have a two class "system" of care and it needs to be fixed. 
What will the fix look like?  Does it mean that the fears will be realized?.  How do you raise the boat for all?

There are underutilized systems and professionals that help raise the boat for all in a very responsible way.  It means investing in both the systems for the insured as well as the uninsured and things will look different.  But will it be less care.  I don't see it that way.  I see specialty trained nurses managing dosing of chronic drugs per protocols.  I see rehab that continues for at risk or frail folks beyond the current limits.  I see chronic disease management via internet based protocols and navigation interventions.  I see navigation over hospital barriers and age adjusted risk assesments for procedures so that post op surprises are avoided.  These are connected by a network of information that works for the patient, alerting them to key changes in their own health.

Does this add cost? - yes it adds resources but it will be absorbed by the decrease in painful and expensive services that are not necessary - CHF admissions, Falls, GI procedures for at risk or frail elderly, reduction in number of prescriptions people are on.  Individualized protocols for treatment for cancers; elimination of unnecessary and painful spine surgeries.  There are many many areas where the science and information are creating choices for patients.  Giving you choices. Major academic medical centers have put these structures in place for their insured patients!

I see a day when Americans will think that they had great care because they used less of the expensive and painful care; yet knowing their chronic health issues and risks were managed so well.

Why recognize leaders?

I just read the list of the 25 leading women in healthcare - I was so excited that I am buying my ticket to salute them today.  It was thrilling. My career developed in the time when you started in the boys club, lucky to have great mentors but also unlucky to have predators that popped up in your future as "references".  It was an era that reminds us all that vigilance in equal opportunity for our daughters is constant.

But after all the effort to forge new opportunities, women are emerging within the traditional ways, but with ethics intact - possibly bruised - but less from "discrimination" than from "cultural immaturity".  Those women who emerge as the leaders have emotional maturity and cultural competence.  They get it; they know what they want to do and they know how to do it within the realm of the current culture, changing it because it makes economic and strategic sense, not because it meets some esoteric theory of fairness.


These women know what they need to get done.  They are focused.  They are unapologetic.  They are principled and charming.  They are right!  They are going after the next best thing...not the best money from the currently successful thing.  They are really entrepreneurial and they are culturally intuitive.  They are strong.

It is a joy to see them recognized.  Deb Proctor for her administrative skill, integrity, guts and ability to think globally.  Carol Keehan for her passion for the right thing and her understanding of managing the politics.  Her focus on the goal, the patient, the community and the values regardless of the detractors.  Sandy Bruce for her entre into a field of landmines and to create a determined focus to turn the organization around with quality leadership and Sally Jeffcoat for her style, guts, breath of vision and focus on the strategic success factors.

I would be remiss if I did not mention Nancy Schlicting who has wowed the healthcare community for years - for strategic turnarounds, for partnerships, for her unbelievable career and for the changes she is making for the future.  Kathleen Sebelius goes without saying is the epitome of the strong ethical politically astute leader.  But more important, she has accomplished what no others have and with grace, openness and a steel spine.

What a wonderful group of leaders!  Strength not in numbers but in individual effort!    I hope that the men with whom you share this space can recognize the substantive difference.  The leadership!

Medicare recipients should be ecstatic about the potential to keep them out of the hospital.

The successfully managed patient will have a system of care called the Medical Home.  It is not one poor primary care person who has responsibility to know too much, but it is a series of information transfers to a single entity to capitalize on the expertise and data available to an array of providers in a system.  Your patient may be sending messages from home from his smart scale or may be managed and assessed by a number of protocols simultaneously and often remotely.

The Medical Home is much more than a primary care physician with a smaller panel of patients.  It is really a system of care that relies on effective transmission of data and implementaion of scientifically established protocols of care than can be deployed to every patient that enters the system.

AHA meeting...this should be fun!

Government shutdown, no budget for last year, no budget for next year, 20,000 people dependent on government money to run their hospitals sitting together, ACOs .

I am looking forward to the following at the meeting:
RISA LAVIZZO-MOUREY, M.D., Jonathan Perlin, MD, Mika (the only adult on cable TV), Leo Brideau and crew on insurance exchanges, and of course the parade of elected officials. 

A fresh (albeit tactless) take on ACOs!!

This is good for a Friday.  Enjoy.  Thanks to my friend Skip Fiordilis for sharing!
http://www.youtube.com/watch?v=lF8bK7AJyL0

ACO road to better outcomes: best practices

The road to ACOs may be paved with some broken hearts and dispirited warriors as they break new (or slightly new) ground on the road to a more perfect quality/cost equation.  On the other hand the learning curve doesn't need to be trial and error.  This is a time for consistent and unwavering application of known best practices.  Sounds impossible...not with the carrots that will be available for strong performance.  And the winners will be the first to understand that...because once the stragglers get on board, the incentives will begin to diminish by necessity ( Medicare cuts will not be a thing of the past).  So my message.  Jump in with both feet if you can maximize the size.

This appears to be a game about primary care but it really could be most effective if it is a game about leveraging the best in specialty care to the broadest set of patients.  What does that look like?  It looks like a CHF protocol for all chronically ill patients to guard against inevitable admissions from the side effects of chemo or radiation.  It looks like a coumidin clinic where nurses manage all patients on blood thinners and essentially take over from the primary care doctors the monitoring of lab results.  It means levels of care in the ER and a number of after hours options for all patients in the system from electronic to actual visits.  It could mean smart technology for patients in program categories.  It looks like each patient is no longer a series of diagnosis but a series of manageable processes and symptoms that trigger intervention.

For providers it means smart technology and reduction in redundancy.  It means comparative reporting to determine group and community standard norms.  It means aggressive risk management and interventions and rapid response, hospitalists and evidence based practice. It means patient navigation.

And you thought you were committing to an EHR and a medical group!

Will you report to your Community Clinics CEO?

No I'm not kidding.  Just think about it.  If the reimbursement goes to the primary care doctors organizations to manage risk, where does that leave you.  Not necessarily in the drivers seat ....but possibly the costly subsidiary!  Yes I am talking to hospital CEOs, soon to be known as facility general managers?? 

It may never go that far, but what if? 

Should you be nice to the Community Clinic?  Should you try to control it?  Should you apply for one of those jobs?  We shall see if the talent gravitates to the outpatient and insurance risk side of the business.  My money is that it will. 

With Ascension's announcement, what if Community Clinics started to buy hospitals in their for profit business line?  No?  Who ever thought Catholic hospitals would be going for-profit.

TO ACO or NOT TO ACO? That is the question!

Or at least that is the debate.  My money is on the organizations that have a solid integrated system plan that can manage medical loss ratios...ie can manage care and outcomes.  And can manage capital investment to proven utilization models.

There is alot of ink or cyber-ink being used to debate whether ACOs are the managed care models of the past; whether they are PHOs or not?  This is not the issue.

Its the economy stupid!  Its the debt.  Medicare, Health Insurance paid by Business and Medicaid will shrink on a per capita basis.  No one is willing to pay what it would take to sustain the healthcare cost growth trajectory.

Hospitals are beginning to realize that they will not "make the kind of money" that they have in the past with an ACO model.  That is a micro problem but a macro solution.  The fact that hospitals will not eat up more of the dollars solves the macro problem.  The micro problem for "health professional"  (hopefully hospital CEOs are beginning to see themselves in this category) is to assure that individual patients have better outcomes with less money spent on expensive hospital care and that the local structures evolve to make that model sustainable.

Or do we just fight it.  Lobby for the end of "Obamacare" and fight for every dollar.  I don't see any future in that  - even if that is the strategy that wins.  I hope we stay the course on this one and begin the painful reshuffling that needs to be done.  The shake out!

Merger, Acquisition...more and more

Seems that the healthcare landscape is "achangin"!  Lots of for profit gobbling up of each other...."consolidation in the market".  And lots of seemingly unheard of activity - Catholic to for-profit.  A once lonely venture in Chicago, the for-profit market is heating up in the state.

And guess who has the longest sustained bottomline - members of for-profit chains.  The big winners in the top tier are for profit (with the non-profit chains running second).  The unsustainables continue to be the independent or inner city hospital where there are few buyers but potentially lots of politics to bolster the bottomline on the brink of disaster.

The latest talks in Illinois between Provena and Resurrection are interesting.  No real news there- just larger.  Both number two in two hospital towns.  Neither has a strong brand.  So where is the magic going to come from?  No large medical group to compete; no academic center wannabees in the mix.  Is it a play to get Loyola to play ball.  Seems like a drastic measure just to get an academic presence in the mix.  Some major decisions to be made.  Vision??  Will they beat the competition in the market by virtue of size?  Size requires more capital, remember.

Silence is golden

I haven't felt like writing during the past few weeks.  Too much talk already in the cyberspace!  But I am wondering whether the magnificent team at Arizona University Medical Center will become the poster children for repeal of healthcare (best care in the world why change it) or reform (you never know when you are going to need world class care and your lack of health insurance will bankrupt you).

I for one still believe that the best insurance would be one national plan where all are enrolled in affordable options.  And affordable includes the 20% deductible when the worst happens.

As the recession hit close friends forcing them into lower pay jobs as they hit middle age, you wait for the shoe to drop.  And for many it did - a triple bypass, a freak bicycle accident, a chronic pulmonary condition diagnosed, major medications.  All bills that at 20% or more deductible seem insurmountable over time.  Its not the first bill...its the third and fourth and twelfth. I do not see how current health reform will  fix the increases in insurance and deductibles that bankrupt so many.  We have to bring costs down and make that trauma care that is so important to all of us, available to all.

New Years Resolutions

1. Wash hands, wash hands, wash hands, and teach hand washing
2. Root cause analysis of re-admissions
3. Examine patient criteria for risk for procedures and evaluate institutional guidelines
4. Explore UV-C technology for infection control
5. Encourage primary care visits that are longer and more in depth
6. Incentivize communication between subspecialties
7. Form multidisciplinary teams for expensive patients - CA surgery, ortho surgery, GI surgery
8. Fast track ERs and connect to primary care
9. Fund and create Medical Homes
10. Establish funds for expensive outpatient drugs
and last but not least. Go on a diet!