Accountability, Responsibility and Change

$1.5 Trillion and Counting


A couple of weeks ago, Health Affairs reported that healthcare spending increased by $750 billion to $1.5 trillion. It was also predicted that by 2017 healthcare spending would increase to $4 trillion. Okay, can anybody without giggling too hard really admit that they can comprehend and understand exactly what $4 trillion means? Monopoly money... it has no meaning except for those that can figure out how to be part of that spending. Hospitals, health systems, medical device manufacturers, pharma, physicians, associations etc., all looking at what piece of the pie is theirs. The economist's know what that means. So what else are we to spend our money on?

Well, that kind of spending is unsustainable and will force concrete action to fix a broken healthcare system. Just what that will look like is any ones guess at this time. Don't fix it and we will have rationing, long waits and a national healthcare system where no one is cared for. And a dollar that so far south of the Euro that it will never come back. Government has enough trouble running Medicare and Medicaid now, what in good gosh almighty makes anyone think they can run a national healthcare system.

A bet and forecast for my money..... Like Chicago politics, once everyone figures out how they get theirs, healthcare reform will happen. Everybody wins except for the consumer......


Medicare Rates Are Cut!


Scream the headlines and the hospital administrators, national leaders decry the action. OK, what does it really mean. First, Medicare is not being cut. Second, it is still growing. Third,what was cut was the rate at which Medicare is growing. And fourth, it is just not the rate healthcare people want. How about instead of crying for what we don't have find ways to be more efficient and productive, reduce medical errors, promote standards of care and become more self sufficient and less whinny.


Having been outside of the hospital part of the healthcare industry now for a couple of years and reading and watching, I never realized how whinny hospital execs are. We are expecting someone else to fix our problems. Maybe its time as healthcare executives we stepped up to plate, reached consensus on a strategy and drove some real national policy agenda and change. Instead we are reactive and acting surprised when someone steps with a solution on issues that we should be leading and then we react with the why it will not work, not the why it will. Oh wait, if we did that we couldn't complain much anymore. No wonder no one takes the healthcare industry seriously. I am sure this really endures me to the industry.


IT Anyone?


Expensive... needed.... and the right thing to do. EMR, e-prescribng, RHOIs (which may be dead anyway) and a whole host of issues besides the technical ones. Seems to me to be the cost of doing business. We all agree that government wants IT, doctors and hospitals want IT, employers want IT from providers and national healthcare leadership want IT and the AHA wants government to pay for IT. Sorry, there I go again not being part of the solution but adding to the let someone else pay for what I need to do for my organization from a cost of doing business perspective.

My simple question is, so why is the government expected to provide the cash to hospitals, health systems and others to move to computerization? Money for IT might just be available if every hospital in the US didn't have to provide every service, piece of new technology, improved efficiency and productivity, reduced medical errors and improved customer satisfaction.

In the end....

These are not simple problems and do not have simple answers. I have made light and poked fun, and I am sure irritated a bunch of people along the way. But at the end of the day, unless we can come together, use a little common sense and ask what is right for all instead of what's in it for me, we could solve these problems. Maybe that's what Senator Obama has figured out, the American people have figured out and we are just waiting for everybody else to catch up.

HIPAA and the Press

The Chicago Bears, Brian Urlacher and HIPAA

No, this is not a joke. It has been most interesting reading sports columnists and broadcasters lament to a great common chorus that no one knows about the extent of Urlacher’s injury and his neck surgery. The Bears aren’t talking, the doctors aren’t talking and nobody else is talking. It is as if some serious plot has developed to keep the real story from the media. Hogwash…..

As a 20 year healthcare executive life changed a few years ago when HIPAA became the law of the land. Simply put, if an individual does not want anything released about their medical condition, treatment, so forth and so on, that was that. No press leaks, no briefings from the Bears, no info from the hospital, doctor’s or anybody else. The federal government has clamped down really hard on the privacy issue and this falls into that. Urlacher is the only person, who can make the decision on who does or does not receive any information about his medical condition or treatments. Who he designates as being able to receive information is prohibited from releasing any content. If you want to know you have to speak to Urlacher.

What you simply have here is that he decided not to allow for the release of medical information. The Bears won’t say anything, the hospital won’t say anything, and the doctors won’t say anything. Why, simply put they are prohibited by Federal law. Big fines, imprisonment, law-suits, malpractice judgments and loss of professional license will result if found violating HIPPA. That’s all it is, nothing more than that.

Gone are the days when tips would be called in. Staff will get fired for that. As a healthcare marketing executive, HIPAA makes life a lot easier for me and not having to deal with the press. Privacy is privacy and the law make no distinction whether you are Joe average or a superstar. Everybody is this same. It does make the media job harder.

So everyone please stop with the grand conspiracy theories and keeping things quite because the Bears don’t want others to know. It’s all about privacy and his wanting some. Everybody is pulling the media chain, you guys give free press and the Bears and NFL are laughing all the way to the bank.

Frankly, as a Bears PSL and season ticket holder, at this point could care less. They will be bad next year and the year after that. I have no confidence in an arrogant coaching and administrative staff, that can’t change and adapt to different situations. They are self delusional in thinking that and believing that they are better than they are. Their window slammed shut and is closed tight for at least another three years.

Competiton in healthcare? Now that's an oxymoron.

A most interesting column appeared in the Tuesday, January 29, 2008 Wall Street Journal "The GOPs Prescription for Health Care", by Grace-Marie Turner. A good read and provides valuable information. Ms. Turner is the president of the Galen Institute and editor of "Empowering Health Care Consumers through Tax Reform", University of Michigan Press, 1999.

But and this is a big but, the premise of empowering consumers is that competition in the marketplace will fix the healthcare ills of the US faces some serious questions. On the face of it potentially true. In most markets competition drives down cost, improves quality and diversity of choice.

Healthcare does not operate as a true free-market competitive environment. It is more complex than the private health insurance, workplace, choice debate. The fundamental problem with the healthcare landscape is that until the very basics of regulatory reform are made to impact and make it a true competitive environment, all the tax reforms, HSAs, etc., will not alter the current crisis.

Right now, tax exempt healthcare organizations through Federal and State regulation and Certificate of Need laws, are able to charge higher prices, form cartels to legally block competitors from expanding services or even entering the marketplace and collude. That does not describe a competitive environment. That sounds like a Justice Department probe for anti-competitive behavior, collusion in the marketplace to fix prices etc. We don't accept that behavior in other industries why do we accept that in healthcare?

I am sure that when the explosive growth of healthcare started motives where high, community good meant something and community leaders were trying to do the right thing at the right time. Today's world is fundamentally different that the 60s, 70s, 80s, or even the 90s. Strong bold regulatory action is needed first.

Unless fundamental restructuring of the tenets of the competitive healthcare market takes place, reform under the various proposals are not possible, unless it is universal and single payer. And heaven help us if we go there.

Healthcare market regulatory reform is something that neither party nor the candidates are addressing, except in some of the best political speak that I have seen in years.

The more things change, the more they stay the same

Economy

With the economy nearing recession it is a safe bet all the talk about healthcare reform and national health insurance will slow down. People want jobs and economic security. That debate is beginning to overshadow everything. Politicians are like a 3 year old child's short attention span and they focus on the flavor of the day. Until someone comes up with that private government combo plan for reform, its dead in the water. Look for incremental change that tinkers around the edges but fails to address underlying systemic issue. If real change is going to come it will have to come from employers large and small. As the old saying goes....Money talks and ........, well you know the rest.

Hospital margins

We all know that hospital margins for the most part have been showing signs of improvement the last couple of years. With the growth in spending in Medicare and Medicaid, and CMS realizing its out of control faster than they even thought, reductions are in the works. That will pace more pressure on margins. Also, hospitals have done very well thank you very much, in the past few years with their investment strategies which has supported margin growth. With the current state of the financial markets, some will take a financial bath. Look for losses especially with the stand-alones going forward. Higher interest rates for bond issues as well because of the sub-prime market meltdown, lower margins etc. As layoffs become more prevalent in the general job market more uninsured will be seeking care further increasing bad debt and adding to margin compression. Oh wait, my bad, bad debt is really community benefit as they like to say.

Mergers and Acquisitions

One would predict that merger activity will increase this year and for the foreseeable future with the economy the way it is becoming. The Justice Department will be looking very closely at these transactions. I have yet to see one where healthcare costs were reduced, duplicate services eliminated and big time leverage was gained for increased reimbursement from payers. Doesn't mean that it doesn't happen, I just haven't seen it.

Error rates

Nearly 100,000 people die every year from preventable medical errors. That's like crashing a fully loaded 747-400 every 1.5 days. Now we all know its unacceptable so why do we continue to allow that that in healthcare? Some payers and the government are going to stop paying for never events. A good start in the right direction. The jury is still out on whether or not P4P programs work. Mess with the medical communities money and you will see how fast the error rate and deaths associated with it goes down. Cynical yes, but true never-the-less.

Have a good week everyone and thanks for reading. Have some news or ideas just send them to themichalejgroup@aol.com All will be treated confidently and anonymity assured.

Quick Hits and Other Notes

Happy New Year everyone.

Jan, 1, 2008 and another year starts anew.

Check out the poll on Certificate of Need.

Quality Ads

Been seeing a lot of hospital quality ads lately. HealthGrade ratings are out touting we are the best. How many people out there really understand that hospitals and health systems have to pay a lot of money to use the HealthGrade logo and rankings? Not many I expect. Five stars, four stars etc, kind of like choosing from a menu at a restaurant. Wish my doctor had admitting privileges at all those hospitals, then we could pick and choose where to go. Like that is going to happen. I'd rather have info about medication and surgical error rate and malpractice suit results, physician qualifications and satisfaction rates.

Hospital Ad Wars

Always fun to watch hospital dueling in the marketplace with ads. Especially in a two hospital town. Lots of ad dollars and the only ones that profit are the local papers and radio stations. The ads are silly, cover nothing, have no call to action and look the same. My doctor and I make the decision of where to go based on my insurance, what's needed and the hospital she prefers to practice at. Humm..... there I go again thinking that doctors and managed care plans are the ones driving where to go, not hospital advertising. Gee, think they might want to work on customer service and improve how they treat people?

New Hospital Opening
Illinois newest greenfield hospital was to open December, 2007. Rumor now has it that it will open on January 14, 2007, over 5 weeks late. Last one was built and opened over 25 years ago.

How are they marketing leading up to the opening? Poorly at best. It is typical of the old build it mentality and they shall come. What an opportunity passed by. I live in the community and little marketing is taking place. Arrogant and Imperial. Each time I go to work and drive past the place its as dark and quite as could be.

I know lets do a some silly billboards with no call to action or even showing where the hospital is, no radio, one direct mail piece and one newspaper ad. Yep, that will sure draw attention. Think that maybe after spending $160 million plus to build it that it would take a little more than that to raise awareness. A couple of weeks to go and a big thud in the market.

That's it for today. Happy New Year everyone

It's about the Physician

Who has patients.....doctors or hospitals?

Somewhere along the way to the informed healthcare consumer and all that hospital advertising about how good they are, the newest piece of technology and the latest greatest renovation as well as how much we care about you as a person (or your spirit, whatever that means), we have may have forgotten about the role of the doctor.... and that is not a good thing.....

Hospitals and health systems talk about "their patients". Healthcare organizations troll for consumers and employers through a variety of marketing techniques. Some have even entered into agreements with insurance companies under capitation arrangements for "covered lives" where they are paid a certain dollar amount per month per life to provide complete care. (After learning that it's not as easy as it sounds and losing millions of dollars, most hospitals and health systems have exited the insurance business. Good move.)

Physician referral programs, RN staffed call centers, community health and wellness programs, service lines in cardiology, neurology, orthopaedics and others, quarterly magazines and newsletter mailings, advertisements and public relations aimed at creating that awareness, usually center around the hospital, clinic or health system. Sometimes, just sometimes, it does center around the primary care doctor, specialist or physician group. Those hospitals and systems that do center their efforts around the doc get it.

Its about the physician......

A contrary view no doubt. But think about this for a minute. When to go to the clinic or hospital and you need a test what do you need? A doctors order. You can't walk into the Emergency Room at any healthcare facility and just go... "My shoulder hurts, give me an MRI". You need a doctors order. Want an aspirin to treat a headache in a healthcare setting, you need a doctors order. Want an antibiotic for an infection filled at your local pharmacy (unless you live in Mexico), you need a doctors order. If the hospital wants to bill for inpatient or outpatient services, managed care aside, they need the doc to put the patient in the bed or send them to the outpatient clinic. No order, no physician involvement, no bill. No bill, no revenue. It all starts and ends with the physician.

But to hear healthcare providers tell it, I belong to them. I don't belong to anyone, but have a relationship with my physician whom I trust and will go where she directs me. It does still happen to be that way for most people. Informed consumers exist and lots of available data is there for all of us to see, but the exception to the rule is the consumer who at the end of the day, will disagree about where their personal physician will send them for care.

What can hospitals learn from this....

Its about a partnership. That partnership is a three way- you, me and my doc. Stop spending so much time figuring out joint ventures, employment options and all the rest. Yes, I do admit some of it needs to be done, any organization worth its salt will look at service enhancements. That is the natural evolution of a business. But focus on the doc. Each year dozens of seminars, books and articles appear about improving medical staff relations, partnering with physicians, strategies for working together and on and on and on. Maybe its about time we learned from that and began to practice it more.

It means putting egos aside and listening. Doesn't mean you are going to do everything the physician wants, but if you listen very closely you might find some simple ways to help the physician practice medicine more efficiently, improve their satisfaction and at the end of the day increase admissions and procedures.

Want a sure fire way to improve admissions, focus some of your improvement efforts on making it easier for the physician to practice medicine in your institution. When the nurse pages the attending physician, make sure they are there when the doctor calls back. If a physicians wants a faxed copy of their ER report, send it. If the doctors office calls Admissions, have caller ID available so the admission representative can ID the doc and respond appropriately. And improve your patient satisfaction. Patients complain to their doctor about your service and care. Docs don't want to hear it. Physicians will send their patient to those facilities where it is easier to practice medicine, where they have their needs meet and their patients are satisfied.

Don't believe me. Take a look at market share data of any provider over time. Seeing only a one or two point market share swing among competing facilities? Guess what, it is not through any great marketing, its about the docs moving patients around to different facilities.

The healthcare organization that can improve physician satisfaction and make it easier for them to practice medicine in the halls of the hospital will gain admissions and outpatient business, which in turn will generate revenue, which, well you get the idea.

I admit it is not so simple with competing medical staff, the movement of services and procedures to different settings and other providers raiding medical staffs. But at the end of the day, if you can understand that it is about the doc, you will be better, the physician will be happier and patients will hold you in a new light.

Not that much different from billing the 1960s is it?

Learning from Europe - Universal Healthcare

The debate heats up.......Again......

Much is beginning to be written about healthcare as it continues to consume an ever increasing portion of the GNP; as the medical care component of the CPI continues its rise outpacing the general CPI; as employers find operational costs increasing due to health insurance expenditures; the 2008 campaign...... Well, you get the picture.

Intense focus will be coming over the next year as the presidential campaign for 2008 heats up, with the Democrats and Republicans putting forth their proposals on fixing healthcare. State initiatives will also force the issue, cobbling together a patchwork quilt of suggestions, programs and hidden taxes to pay for the "universal" coverage. There will be some new proposals, but I for one expect much of the same. Looking at past history, nothing will really be solved until both parities engage in a discussion of two very basic questions: Is healthcare a right or a benefit and how/who pays? These are the two unspoken issues and questions which both parities skirt.

One could make the argument, that the Democrats view healthcare as a right by their proposals and the Republicans view healthcare as a benefit by theirs. Still, who pays and how? My bet is that in the end universal healthcare under a one payer system here won't happen. Too many interest groups, too much politics, and with billions of dollars at stake on all sides (forget the quality argument for a while) a universal system just won't fly. I would expect to see some kind of hybrid between universal and private, similar to what is found in Europe. That is...... if we are willing to learn from other parts of the world and not have to reinvent the wheel every time the subject comes up for debate.

European Healthcare

Having worked for a European medical device manufacturer and traveling Europe seeing healthcare in action in some hospitals, there are some true misconceptions in the American healthcare community about what is considered healthcare delivery and payment in Europe.

Not all but most senior executives don't have a clue about what is going on in Europe regarding care or payment. I doubt that the politicos do either. Not bombastic or self serving are those statements. I come from hospital senior management and am guilty of the "if its not invented here, its not worth anything" syndrome. And that attitude considering the seriousness of the topic is just not acceptable any longer. Take away the signage in different languages in a European hospital and you would never know you were not in an American hospital.

So, lets look at a couple of myths.

OK first myth... healthcare is paid solely by the government

It is not a universal one size fits all healthcare payment system in Europe. They leave that to the Canadians. There are government programs, private insurance programs, employer sponsored health insurance programs. Consumers have much higher deductibles than what we pay and a greater emphasis on personal responsibility in maintaining health and wellness. Payment is a combination of various healthcare mechanisms that we too have here in the US. It is a complicated payment maze. But everyone gets care, everyone gets primary care and everyone gets quality care at the right time, in the right amount, in the right setting.

Now in Europe they have some very real misconceptions about us as well. The most important was understanding the difference between 45 million uninsured and 45 million Americans not getting care. They equate uninsured with no care. After many long sessions, people I worked with began to understand that in America, being uninsured doesn't mean that you don't get care. Yes, the care may be inappropriate utilization of healthcare resources by individuals and families over utilizing emergency rooms, which when treated earlier in a primary care setting would have been the preferred option, but people do get care, they do get surgery, they the do get the drugs they need.

Second myth......The hospitals and health systems in Europe don't face the same operational issues we do

Sorry to disappoint everyone, but they do. Declining reimbursement, IT consuming ever greater portions of capital budgets, the need to reduce medical errors, lack of qualified medical professionals, increasing productivity and efficiency, decreasing costs, improving quality, the shift to outpatient from inpatient care, etc, etc, etc. Matter of fact, it may even be more difficult in Europe as each country has its own language, culture, regulations, payment systems, etc. One size does not fit all. On the HIT side, many countries are farther advanced on the implementation of the Electronic Medical Record that we are. Germany and France are good examples.

Third myth.....What happens in Europe or the rest of the world for that matter doesn't effect me

Yes it does. Nothing is new in healthcare. It has been done already somewhere in the world. Its more of a question of discovering the issue, what they have done, how the solution is working and what parts of their solution will work for us. Sorry to say but we are not best in breed. If we were, then why do so many American companies have difficulty in selling their HIT and other solutions oversees. Lots of issues there besides the inability to customize their solutions for different markets, but that's another Blog for another time. We could learn a bit from how Europeans have approached the healthcare coverage issue, the provision of medical care and how it all works together.

Europeans have answered those two basic questions, is healthcare a right or a benefit and who pays and how.

What this all could mean

Clearly we are at a crossroads. We already have a tiered healthcare system that is neither reasonable from a care perspective or socially acceptable. Its easy to medicalize social problems (which is what has been done) and blame the medical community for the indecisiveness of state and national leadership in addressing this issue. Our medical care system today is based on those that can pay, those can can pay some and those that can't pay anything at all.

Individuals, government, employers and healthcare providers must all come together to reach a common understanding. I for one believe that universal coverage is a possibility, but I do not for one minute believe that it is the sole responsibility of the government. It is a partnership. A solution to a societal crisis that can be based on what has happened successfully in other parts of the world.

For the future

This isn't the last writing on this topic. It's complex. Holds many unknowns,. And as the presidential campaigns become more vibrant with proposals coming forth, much more will be written on this topic.

But life would sure be a lot easier if we could learn from others like the Europeans and not make the same mistakes.