Perspectives
The Future of US Healthcare
by Barry Bittman, MD
It’s not surprising that every hospital and health institution in America is facing a substantial degree of uncertainty concerning the future of our nation’s healthcare.
While the writing on the wall certainly includes Accountable Care Organizations, Bundled Payments, Insurance Exchanges, Core Measures, HCAHPS, Meaningful Use and Value-based Purchasing, the precise nature of that which will ultimately shape and enable our healthcare system to survive is at best, uncertain.
The real question is how can we improve and sustain our healthcare for future generations? Highly politicized, the Affordable Care Act is poorly understood and widely debated. Yet what appears to be universally agreed upon is a series of remarkably straightforward goals referred to as the Triple Aim: improving the health of populations, improving the experience of care, and reducing per capita healthcare costs.
The pressure is building. Undoubtedly, something has to give.
According to the Centers for Medicare and Medicaid, National Health Expenditures grew to $2.5 trillion in 2009, actually more than $8,000 per person, or 17.6% of our Gross Domestic Product. CMS suggests National Healthcare Expenditures will balloon to $4.48 trillion in 2019 or 19.3% of GDP. As a reference point, contrast this with our total actual federal spending in 2009 equal to $3.5 trillion yielding a resultant budget deficit of $1.5 trillion.
Bottom line – we’re no longer running on vapors – the tank is empty and we’re out of funds. Beyond any reasonable doubt, our deficit situation cannot persist despite all political bantering over healthcare reform or debt ceilings. And while some have challenged the WHO’s ranking of the US in 37th place among the world’s health systems just behind Dominica and Costa Rica, it’s a fact that healthcare spending as a percentage of GDP distinguishes the US as the world leader. So does our ranking as number one in the world for cheese production (and not surprisingly, obesity) compared with a shamefully incomprehensible ranking of 47th in infant survival.
Compound our challenge with more than 50 million uninsured Americans and an additional 25% underinsured, and the nature of the ugly beast that’s rearing its head becomes apparent.
And if you believe that our present challenges are great, just consider that there are more than 40 million Americans age 65 and over in the US and a projected 80 million seniors in 2040.
While these staggering numbers could keep a building full of actuaries arguing for a year, it’s not surprising that most hospitals fear Medicare, Medicaid and commercial insurance payment cuts.
Neither political party is prepared to openly duel over the matter, yet somehow most healthcare executives believe the ax is about to fall and funding cuts are going to decapitate the highly vulnerable organism we refer to as our ill-fated American healthcare system.
And while that fear is not unjustifiable, the real question is whether or not our present challenges can be solved with a purely economic solution.
Frankly I do not think so. I also don’t have a crystal ball to foretell the future.
Yet I am convinced that each hospital and healthcare system in America can better prepare itself for weathering the storm regardless of the wind’s direction. And we must not rely on a federal mandate to do so.
Rather than fretting about future cuts or policy changes, waiting for the sky to fall or contemplating early retirement, we must now work together diligently toward the Triple Aim. You might be surprised to learn how we can effectively reshape what we already have – a broken system supported by the largest per capita healthcare spending in the world.
The real question is where do we begin?
The answer is a new vision - our rapidly expanding fee-for-service system must give way to focusing on prevention, eliminating wasted services and procedures and reducing costly admissions. There’s never been a better time to break down the healthcare silos and barriers that impede communication and coordination across disciplines. This predictably results in devastating care gaps.
A new standard must be set to ensure that doctors, hospitals and third party payers work together cohesively for the well-being of the community. We must voluntarily and proactively develop and adopt an unprecedented level of coordination between physicians and caregivers, hospital departments, community providers, and healthcare institutions across town and across the nation.
Sharing of medical records, information, evidence-based solutions and best practices must take precedence over competing at practically any cost. Fragmentation must give way to a reliable continuum of care within a comprehensive patient-centric community care network without walls that replaces the building once affectionately referred to as the hospital. Patients and families within this network must be encouraged to take an active and meaningful role in healthcare decision-making and end-of-life care.
And when we finally focus on the fact that a mere 5% of our population utilizes 49% of our healthcare resources, the prospect for developing an exemplary high quality sustainable US healthcare system suddenly becomes clearer. An interdisciplinary healthcare approach orchestrated in a caring, coordinated manner is doable and achievable, within our grasp and ultimately within our budget.
Through evidence-based interdisciplinary prevention strategies and true care coordination with an emphasis on improving outcomes along with the overall patient experience, as a nation we will not only survive… we will thrive as the best healthcare system in the world.
Productivity VS. Quality
by Barry Bittman, MD
Many independent and employed physicians see themselves trapped between two opposing forces that impact their practices: productivity and quality.
Productivity, as measured in our present fee for service model, is often documented in terms of Relative Value Units (RVUs), benchmarked in accordance with annually-updated data compiled by the Medical Group Management Association (MGMA). Volume-based incentive payment systems often rely on MGMA data and other factors to establish total compensation packages.
Quality however has been more difficult to define. Essentially it reflects how well hospitals and physicians are taking care of their patients. Quality is typically referred to in terms of core measures or specific aspects of “best practices” that can be quantified. In a perfect system, productivity should exist in harmony with quality.
Undoubtedly however this is not a perfect world. The real dilemma begins as the quest to improve productivity tends to advance at the expense of quality. The decision to spend additional time with a patient for the purpose of offering a more comprehensive patient-centered approach may boost quality at the expense of productivity. In contrast, increasing throughput by seeing more patients in a particular time frame yields substantial potential for decreasing quality, widening care gaps and increasing medical errors.
While some healthcare experts would argue that enhancing both productivity and quality simultaneously is possible, at some point this equation becomes constrained. In fact, increasing productivity beyond a certain point has a tendency to evolve into a futile and dangerous exercise. The real problem however is not the goal, but rather what I term the in-the-box construct that remains the center of focus for creating a better yesterday.
Consider the following assumption:
productivity times quality equals a successful healthcare delivery system
As productivity or quality increases, the healthcare delivery system improves. Conversely, as either diminishes, healthcare delivery suffers.
As a result, many physician office practices employ extenders (nurse practitioners and physician’s assistants) who also theoretically serve to boost quality as physicians can now devote more time to certain patients with more intense or critical needs. Yet in a real world environment, the outcome measure ultimately tied to the success of the extender is volume.
That takes us back to our in-the-box construct. Simply stated, perhaps our underlying assumption is incorrect. While this may seem rhetorical at first, a closer look at what we assume to be a successful healthcare delivery system reveals a host of revealing questions and insights.
Perhaps the best place to begin is redefining this construct as:
a sustainable cost-effective strategy that optimizes patient outcomes and care experiences equals a successful healthcare delivery system
While you may be anticipating that I’m about to suggest surprise layoffs and charging overworked staff for coffee in the lunch room, such is not the case. Cost-effective does not refer to slicing and dicing physician reimbursement with the dull end of a discarded scalpel either.
Rather, the concept targets more effective healthcare spending. The good news is that in order to develop a sustainable cost-effective strategy, we have to learn to work smarter rather than harder… and we must begin working together in a collaborative manner.
“Why should that be considered good news?” you may be asking.
The answer introduces two out-of-the-box strategies: 1) improving quality through enhanced care coordination and 2) reimbursing physicians for achieving or exceeding benchmarks that reflect positive patient outcomes!
While this approach might appear bold at first, these processes are evolving far more quickly than anticipated as evidenced by two recent CMS announcements.
Frankly this shouldn’t be surprising. As a nation, we’re out of funds and well into deficit spending. The survival of our disjointed American healthcare system clearly depends upon focusing on outcomes rather than volumes.
CMS recently proposed a reduction in the physician fee schedule beginning in 2015. Parallel to the Value-Based Purchasing guidelines set forth for hospitals, fees will be reduced for physicians who do not satisfactorily follow quality guidelines. The program is structured to begin with a 1.5% fee reduction that will extend to 2% in 2016 and subsequent years.
In addition to this novel fee restructuring strategy, a new HHS program announced recently entitled the Comprehensive Primary Care (CPC) initiative, has substantial potential for positively impacting patient care. According to the CMS Innovation Center, the CPC initiative will focus on risk-stratified care management; access and continuity; planned care for chronic conditions and preventative care; patient and caregiver engagement; and coordination of care across the medical neighborhood. This shared savings strategy will include a per beneficiary per month care management fee in addition to fee for service reimbursement for selected primary care practices. Essentially, this initiative rewards medical practices for enhancing care coordination in concert with Triple Aim objectives— better outcomes, better care experiences and lower per capita cost.
According to CMS, “Practices will have discretion to use this enhanced, non-visit-based compensation to support non-billable practitioner time, augment care teams (e.g. care managers, social workers, health educators, pharmacists, nutritionists and behavioralists) through direct hiring or community health teams, and/or invest in technology or data analysts.
Ultimately, business as usual will no longer be the same. In the future physicians will not get paid for the amount of care they provide, but rather for the quality–based outcomes they achieve. In contrast with prior initiatives that unfortunately tended to limit patient care and services to achieve cost-effectiveness, this new era of healthcare ushers in a novel approach for achieving affordable care in concert with improved outcomes and care experiences.
While the future of American healthcare clearly rests on building a sustainable cost-effective strategy that optimizes patient outcomes through exemplary care coordination, the buck doesn’t stop here. We must work together to develop a rational strategy that effectively engages patients in taking an active and meaningful role in their own health and well-being through evidence-based prevention strategies.
Care Coordination: the future of sustainable healthcare
by Barry Bittman, MD
The challenges of ensuring sustainable high quality healthcare for our nation must not be underestimated. This highly complex system with current expenditures exceeding $2.6 trillion per year cannot continue in its present state.
The system is broken.
While our nation expends more than 17% of its gross domestic product on healthcare, our global ranking in comparison to other health systems is deplorable. There is no future for a poorly ranked healthcare system that drives us to a frightening degree of deficit spending.
Our fee for service approach coupled with fear of malpractice claims undoubtedly generates unnecessary procedures and resultant expenditures. It’s also a fact that 19.1% of Medicare patients are readmitted within a month of hospital discharge. 56% percent are readmitted within 6 months.
Approximately half of the patients with chronic conditions like heart disease or asthma actually either miss doses or don’t take their medications as ordered. Non-adherence to medical regimens accounts for a great deal of wasted spending and potentially avoidable costly admissions. And furthermore, ignoring the challenges of caring for our burgeoning elderly population is as unrealistic as setting off on a cross-county trip with only enough money in your pocket for a single tank of gas. Be assured that you are not going to get far.
The real question is how and where should we begin.
Essentially we have two distinct options. The first is a purely economic solution — slicing and dicing the overall healthcare delivery system — cutting back on payments to physicians and hospitals while limiting access to costly treatments and medications. While overall expenditure reduction is assumed to be immediate… the prolonged negative consequences are both far-reaching and unsettling. The second option includes novel strategies designed to improve care coordination, prevention and personal engagement in health and well-being.
Let’s focus our attention on a novel care coordination strategy.
Let’s begin by getting back to our roots – or where our nation’s healthcare actually began. Hospitals were originally founded by community volunteers who were intent on taking care of their neighbors in need. In a similar manner, our patient-centric strategy is based on what we refer to as a Community Care Network – a CCN.
I know what you’re thinking — we’re just adding another layer of cost and complexity to an already overburdened system. I assure you that’s not the case.
The CCN is actually a cost-effective extension of a community hospital that operates seamlessly with other local health agencies to support the ongoing needs of its patients through physician-directed coordinated care. Consider it an all-encompassing healthcare system without walls — or a patient centered medical home on steroids. We actually like to refer to it as a patient-centered medical condominium.
The CCN is effectively run by the hospital. It’s comprised of a physician-directed interdisciplinary team of nurses, counselors, social workers, nutritionists and ancillary support personnel. The CCN’s mission is to provide the highest quality continuum of compassionate, outcomes-based, patient-centered, culturally-sensitive healthcare. Each patient’s choice is respected, and our quality measures are outcome, rather than process-based.
We adhere to a “no-discharge” policy. We will not abandon people in a sea of seemingly overwhelming healthcare challenges where they struggle to stay afloat.
Our commitment extends beyond the confines of disease management — addressing socioeconomic, educational, psychosocial and behavioral factors, as well as each person’s adherence potential. Our quest is to identify and eliminate medical errors, care gaps and obstacles to receiving healthcare whenever possible. The CCN also focuses on reshaping healthcare behaviors and promoting early interventions to prevent the development of ambulatory care sensitive conditions (ACSCs) and unnecessary complications, hospitalizations or readmissions.
Now I know what you’re thinking. It must cost a fortune to deploy the army of individuals needed to accomplish these lofty goals for a community! Surprisingly it doesn’t … due to the fact that we are engaging a rather unique workforce! Through an unprecedented collaboration between Meadville Medical Center and Allegheny College, pre-med students are engaged in a formal credit-based training program that enables them to serve as health coaches supervised by the CCN interdisciplinary team.
How is that possible?
The answer is rather straight-forward. Students are formally trained by a faculty comprising physicians, a nurse coordinator, social worker, psychologists, nutritionists, an ethicist and even a healthcare attorney through a formal semester-long didactic interactive college course.
Upon completion, these extraordinary students begin a practicum by shadowing members of the interdisciplinary team and are thereafter progressively deployed to serve as health coaches within the community. Under team supervision, each health coach’s primary responsibility is to inspire and motivate our patients to become more actively engaged in their health and well-being. Health Coaches work with CCN health professionals to reduce what ultimately falls though the cracks and escalates into the realm of costly often overwhelming problems on many levels. Examples include missed appointments, medication reconciliation errors, misunderstandings and inability to adhere to prescribed health regimens.
In this CCN-based Health Coach model, everyone wins.
Our patients benefit from a reliable dedicated patient-centered continuum of care. Our physicians receive the support they need for helping to care for patients with a myriad of challenges in multiple domains. Our community realizes enhanced overall health and well-being. Our student Health Coaches benefit from real world experiences — one of the most important life-shaping determinant of success for our evolving healthcare workforce.
“Too good to be true,” you might be thinking. Too expensive to justify for the average hospital?
While these are good questions, we have great answers.
First, our dedicated healthcare faculty is not paid — they donate their time to our formal training program. In fact while we only ask that they present for one lecture, often 5 or more of our faculty members work together for each class.
Next, our Health Coaches do not get paid either — they receive college credits for their participation in both the didactic sessions and practicum. In effect, we are vastly expanding the workforce with minimal cost other than supervision!
Finally, we believe that the program cost can be justified by the overall savings generated by the CCN coupled with improved outcomes and the reduction of proposed penalties associated with excess readmissions.
In conclusion, this innovative hospital-based, culture-shifting healthcare strategy is effective, affordable and sustainable. From a humanistic perspective, it is the right thing to do.
When properly implemented, it has great potential to serve as a giant step toward radically reshaping our nation’s healthcare for this and successive generations.
The Patient Experience
by Barry Bittman, MD
World renowned business strategists, Deming, Juran and Drucker clearly shared a tried and true philosophical insight that finally seems to be coming back into vogue in our present healthcare system — quality and customer satisfaction are inseparable.
As a physician who assumes the role of change agent, recognizes the value of shared responsibility with the hospital, and strives to optimize quality through creative healthcare delivery systems, I strongly support the notion that we need a guiding light to stay on track.
None is more powerful that what we refer to as the "patient experience."
As a healthcare executive, your leadership and facilitator experience will be called upon for a variety of projects and programs that will ultimately affect your organization’s relationship with its patients. None will have more impact in this regard than a dedicated focus on improving the patient experience. In order to succeed, you must see yourself as a champion or advocate for those you are privileged to serve. Your responsibility includes the creation and development of novel strategies for the promotion of your patients’ interests.
Over the years, I’ve made it a habit to ask new employees to identify and discuss our competition. Most simply shrug their shoulders and offer the obvious — a hospital in a neighboring community, the clinic down the block or the multi-specialty group in the professional building. They typically focus on comparing similar services such as labs, x-rays, health screening, stress tests, etc.
On the most superficial level they are correct — people have a tendency to compare such services. When I proceed to challenge them, and throw in a name like L.L.Bean, the new recruits appear perplexed. Their reflex response is expected. What does a sportswear store have to do with healthcare?
My answer is… everything!
It’s a fact that while people have a tendency to compare products, what’s often forgotten yet seems to matter the most is the customer experience. In healthcare, we must raise the bar since it’s the best experience that stays in mind regardless of where it was offered. It’s a fact that people tend to rate organizations to a great extent by the attitude through which goods or services are sold or delivered. It should not be surprising that they compare us (our hospital) to those indelible best experiences that are difficult to forget.
Taken directly from L. L. Bean’s website, the following quote reflects both a philosophy and a real-world commitment shared by its employees, “A customer is not an interruption of our work... he is the purpose of it. We are not doing a favor by serving him... he is doing us a favor by giving us the opportunity to do so.”
L.L.Bean refers to itself as “a trusted source for quality apparel, reliable outdoor equipment and expert advice for more than 95 years.” The company, having grown from a one-man operation to annual sales of $1.5 billion, can teach us a number of important lessons.
Perhaps the best way to begin to understand our patients is to track them through existing processes. When was the last time you observed the hospital registration desk or the lab waiting area? How much time do your patients spend in the ER for both emergent and non-emergency care? How long does it take to get lab and test results? For someone in distress, when is the next available counseling appointment? How long must a family member be separated from a loved-one post surgery (and why)? Your answers are likely to uncover unnecessary sources of intense anxiety that have a tendency to weigh negatively on the overall patient and family experience. Yes, the family is our customer as well!
Essentially these questions reveal only the tip of the iceberg. Perhaps it’s time to dig a little deeper. What are the real obstacles to receiving care in your institution? How many patients with potentially modifiable risk factors are lost to follow-up? From a business perspective, why would your hospital even consider leasing a billboard, when a similar expenditure dedicated to improving customer service could yield a far greater return on investment… and a satisfied patient?
Is your hospital truly service oriented?
If you cannot answer these basic questions, perhaps it’s time to raise the bar on the patient experience!
Every hospital must strive to improve its HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores. For the first time, the patient experience, measured by the HCAHPS twenty-seven question survey, directly impacts reimbursement and your bottom line.
By now you’re probably reflecting on your hospital and realizing that room for improvement is so vast that a reasonable approach is bound to require a coordinated wide-ranging all-encompassing effort. Undoubtedly you are correct.
The question that immediately comes to mind is, “how does your hospital set forth to accomplish this goal?”
The answer lies in developing a coordinated interdisciplinary patient experience strategy.
Consider the following steps:
Begin an interdisciplinary Patient Experience Council.
Champion an ongoing institution-wide strategic initiative.
Develop a unique set of comprehensive satisfaction metrics.
Reward, report and celebrate innovation.
Realize the benefit of creating a cohesive workforce.
Inspire Leadership within the ranks.