Healthcare Reform: What Might it Look Like?

I showed this photo to an acquaintance who happens to be an ER nurse. The turkey vulture in the image was sitting on a tree next to the freeway, and the title of the photo was Waiting for Roadkill. That nurse said, “hey, that’s how we feel about ourselves working in the ER!”

There is that certain irony in healthcare in that we get into it because we want to help. But perversely we need people to get sick or injured in order for us to help, to have jobs, to get paid, and fulfill our personal mission to do good. One person’s worst day of their life can be our chance to make a difference, or to have an adrenaline rush or an intellectual challenge.

The same irony applies to healthcare organizations: the unhealthier the population we serve, the more likely that the organization can fulfill its mission, especially if that population has a payment source.

What about the future mission of healthcare organizations? The mission will probably not change, but:  Can we continue to sit like the vulture and keep our beds full and our outpatient departments busy, or is something new headed our way? Below I’ve listed some of the changes that we can expect as part of healthcare reform. And if you are thinking that the Supreme Court is going to strike it all down and we will return to the good ol’ days, think again: The current system is simply unsustainable. These are the good ol’ days! Reform itself will change, but there will be reform of some sort.

Moving From
Paid to take care of sick people. The more procedures and episodes of care, the better the revenue stream.
Moving Towards
Paid to keep populations healthy; the less that high cost care is provided, the better the bottom line. Encourage use of seat belts, obeying speed limits, eating healthy, ambulatory services and so forth.

Moving From
Set our prices and make up for losses on charity and government-paid services through profits on commercial insurance (cost shifting).
Moving Towards
The expectation that all payors will gravitate towards the level of payment made by Medicare. There will be nowhere to cost-shift to.

Moving From
We write things down, scan it, and then we file it away. A box of paper costs $10. Pens are ten cents.
Moving Towards
We document electronically, communicate the information through all levels of care, and assemble the collective data in novel and useful ways to guide our decisions. The patients’ records follow them wherever they go. A comprehensive EMR costs millions of dollars.

Moving From
Do our best and charge for our efforts, even if sometimes we have to re-admit or do-over.
Moving Towards
Payments will be at risk based on measures of quality and patient satisfaction. We will have to absorb the costs of our errors.

Moving From
We do our thing, doctors do their thing.
Moving Towards
Alignment of physicians and hospitals into some version of coordinated care organizations.

Moving From
We do our thing, nursing homes, home health agencies, outpatient providers do theirs.
Moving Towards
Single payment per episode of care, and other “bundled payment” schemes

It will be a challenging time. You’ve probably heard the old saying that “no money, no mission.” Some organizations will likely not survive the changes. I’m confident that the organization that I work for can survive and possibly even thrive in the “going to” future world, but that period of transition will be incredibly challenging because the incentives and payments now and in the future are polar opposites.

Here is what I know rehab providers can do to prepare that is within our control:
1. Reduce costs through control of expenses.
2. Learn how to optimize and most effectively use services. (For an example, in outpatient PT will 3 visits per week be more effective than 2 visits per week? Challenge the conventional wisdom and go with identified best practices.)
3. Where ever possible, measure quality and strive to be the best.
4. If we have an established way of doing things, do it that way always. Variation is costly and leads to errors and uncontrolled processes.
5. Challenge the way we do things, but remember that in a complex system each thing we do is tied to many things that others do; any proposed change needs to be carefully evaluated to avoid unintended consequences.
6. Focus on the mission, and have fun.

Many people get anxious when they face change. I see it differently: It’s an opportunity to become an agent of change, to make a difference in how we do things for years to come. This is a time when we all need to engage in adapting and molding our work to the new future.

July Management Retreat

Last Tuesday the leadership of Asante gathered at our Smullin Center to spend the day focussing on another one of our strategic goals for the organization.  This day's topic was regarding our relationship with the medical staff.  I found it very informative even though the information was both disconcerting and very complex.  I'll try to summarize the 8+ hours of meetings into a few paragraphs here.

The underlying story is that healthcare is entering into an era of unprecedented change.  Reimbursement can no longer be as it has been, and as we move into a period of value-based purchasing our need to respond will determine our ability to survive.  It is clear that "value"  (outcomes, satisfaction, cost, health of the population) is driven at least as much by physicians as by hospital staff.  Without physicians who align their behavior with the goals of the organization, we simply cannot be successful.  And, for physicians who choose the path of autonomous practice, the future for outlyers looks very risky indeed.

So the path of Asante is to better align our physicians' interests with the goals of the organization.  This alignment has many forms, but includes increased employment of physicians by the hospital.  Those innovative arrangements are yet to be completely evolved, but it is clear that in the next few years the tone and tenor of physician relationships will change radically in the Rogue Valley. 

In perhaps the most radical departure from the past, we will not work with physicians whose goals are at odds with those of Asante, or whose behavior and customer satisfaction detracts from our overall results, or who display a "my way or the highway" attitude.  We will see some physicians hit the highway.

This will be disruptive.  Since it's largely new territory, we'll have some false starts to our initiatives.  Common interests will create strange bedfellows, and former best friends may depart.  Interesting times.

Part of the day consisted of six physicians (three from each hospital) sitting on a panel for one hour, and discussing on stage what it's like to practice in our system.  It gave us a flavor for their challenges and needs.  Here's the bullet points that I took away from that discussion:

• They need information.  Quickly, easily, and seamlessly.  They need efficient work processes that allow them to be as productive as possible.
• They need to trust the hospital leadership.  And they need to hear about follow through on concerns.
• Physicians are focussed on the patient experience.  When the patient is seen on followup, they want to hear that the experience was positive.  And they all agreed that it takes very little to turn the experience into a negative one.  It can be as small as a bandage left on the floor of the room, or (more commonly) delays in answering call lights.
• Physicians, especially surgeons, do not want us to un-do what they have done for the patient.  Safety, teamwork and attention to detail are critical to success.

There was also a delightful exchange between a cardiologist, an OB-GYN and a colorectal surgeon about the most important organ of the body.  The cardiologist, of course, said it was the heart.  The OB stated with certainty that it was the vagina.  The surgeon had the last word, insisting that the rectum was the center of the body!

Next was a discussion of our pending implementation of the EPIC electronic medical record.  That work is getting underway now, and based on experiences at EPICs other sites it will solve many of the communication, efficiency and safety concerns of physicians and the hospital.  This will be one of our very highest priorities until go-live in spring of 2012.

The next few years will not be for the faint of heart.  This will be a time of uncertainty, very hard work, and stress.  It is also the time that we all have the opportunity to set the bar for the best 21st century healthcare system in our region.  I'm convinced that it will be Asante.