hospital impact

by Nick Jacobs

What’s this generation coming to? It started some years ago with new rules for residents. They no longer were permitted to be worked 80+ hours per week as part of their residency. In fact, many residents actually keep time sheets and then tell their MD/Professors when their work week is complete. It wasn’t that many generations ago that student nurses and residents were the only people working the night shift in even prestigious medical centers.

What else is happening? New generations of physicians are actually seeking to attempt to balance their work time with their free time. A front page article in the Wall Street Journal by Goldstein reported that U.S. medicine is in the middle of a cultural revolution. According to the article, young physicians are beginning to challenge the fact that they must be available to treat patients around the clock. According to President Ronald Davis, M.D., “There has been a sea change in how young physicians today balance professional responsibilities and personal needs, compared to their colleagues from a few decades ago . . .Physicians who manage their own stress and feel happy with their own daily circumstances are probably better physicians.”

As a hospital CEO in Pennsylvania, we are seeing “The Perfect Storm,” as catastrophic liability insurance is no longer available to our physicians. Ninety plus percent of our State’s finishing residents are leaving. The newer physicians who are considering staying in State are actually demanding free time, comprehensive call coverage, and weeks of vacation and continuing medical education time. Quality of life issues?

So, as 78 million Baby Boomers head toward the proverbial wall, we not only have a significant shortage of gerontologists and other sub specialists, we are also faced with young, smart physicians who actually want a life. Hold onto your hats.

by Tony Chen

I have an idea that I wanted to share with you - please give me your honest opinion (i.e. you can tell me if I'm crazy!). I would love to find others to collaborate with on this. So, if you're interested, contact me directly (tony at hospitalimpact dot org) or comment below. Obviously, the idea is still very rough, but hopefully you'll see where I'm heading. And hopefully, we can refine it together.

What do you think about a new a philanthropic/VC hybrid that invests in preventive health projects that yield at least 338% ROI? (thus the name "The 338 Foundation.")

I'm going on 2 key assumptions:
1. Prevention is one of the biggest opportunities in healthcare. We don't have a healthcare crisis as much as we have a health crisis. We need to pour out a lot more creativity and resources for prevention/healthy living.

2. The biggest obstacle around prevention is a lack of (or misaligned) incentives. No one wants to invest the real money for what's truly best for the patient because these potential investors (whether they be hospitals, insurance companies, pharma, or other companies) make the investment, and others would get the benefit.

For example, a hospital may choose not to hire a chronic disease mid-level practitioner because the "cost savings" it generates essentially goes to the insurance company. Maybe the hospital saves some real costs from reduced ER visits, but not enough to pay for itself. With so many pressures on margin, I can't blame them for that decision. Insurance companies are investing in some disease management 2.0 items, but I doubt they will ever really invest because their members stay with them for only a few years (I've heard 2.5 years?). So any investment they make into keeping the patient healthy is most likely benefiting their competitor (i.e. who ever happens to be their member's insurance company 5 years from now)

It's the classic case of no one wanting to do what's "right" because they pay 100% of the costs while reaping only a fraction of the benefit. So this idea would turn that notion on its head by getting all interested parties to pool their resources together into initiatives that collectively will pay off for all of them.

How I could see this playing out:
- Some smart, collaborative healthcare people could solicit and collect all potential ideas/projects/research and rank them by ROI & approximate benefit to each industry.
- We would welcome individual and corporate donors to the foundation.
- We could do a targeted pilot (i.e. partner with the City of Chicago - i.e. trying to get Chicago to be the "healthiest city in the U.S. by 2015")
- Solicit proposals/applications from organizations who can most effectively implement these projects.
- Fund based on potential ROI and effectiveness of organization's implementation proposal.

So, what's the significance of 338? I'll leave that as a riddle for you. It has to with an important year coming up in our lifetime.

(one side note: One of the ideas I would love to see funded is a savvy viral advertising campaign that changes how people think about their lifestyle habits, like how http://www.thetruth.com/ reduced teenage smoking)

Imagine investing in a fund that yields $3.38 savings/benefit for our country for every $1 we put in.

Please comment/brainstorm with me! Is this crazy or what?

by Nick Jacobs

My first health care administration job began in 1988. It was a warm September morning when we met around a large table to examine the financial report of the hospital. The CFO reported out the income from operations, and, although I was new to this particular field, it struck me that all we were looking at was the inpatient report. When I asked where the outpatient information was, he replied, "Oh, we don't have any way of capturing that information." To which I asked, "Isn't that at least 50% of our business?" The answer of course was positive. It was at that very moment that the history of health care management came crashing in on me. Not unlike a University, if the money didn't balance, you just raised the tuition, or, in our case, the costs. Many refer to that time as the "good ole days."

This week, the Wall Street Journal had a blockbuster article that should have been entitled, "Dah." It was about the new wave in hospitals to collect cash upon registration for deductible insurance costs. It was entitled Hospitals Demand Cash Upfront from Patients. It's a revolutionary new idea in hospital billing where hospitals actually are making medical care contingent upon up front payments. At least that is how the WSJ depicted it.

In my world, it does not seem quite that drastic. Hospitals are just trying to collect those payments that seem sometimes rarely to be collectible. We do not deny access based on their ability to pay.

Clearly, bad debt is becoming more of a problem for us each and every day, and this is just one very late attempt to function like a business.

We need help, and, not unlike physician offices, why is it wrong to ask for co-payments as the patient enters? Your comments are welcome.

by Tony Chen

We've been talking about how hospitals and social media mix (and don't mix) for a while now. A while ago I wrote a little on whether hospitals should blog and more recently, I provided some examples of how hospitals are utilizing these new technologies today.

Health 2.0 as a topic is about to hit mainstream. Do you know how I know that? Simple - the California HealthCare Foundation just did a 28-page report (PDF) on it. While I'm sorta joking, give them some credit for tackling these emerging issues in healthcare. Case in point: they published a very influential and compelling report on retail clinics back in June 2006, when these clinics number in the dozens, not hundreds (almost thousands now!).

We all know that the trend of web 2.0 is hitting all industries, so it is inevitable healthcare will be impacted as well. I think the real innovation will come when consumer-savvy folks put their heads together with web-savvy folks and medical experts. We will see new types of patient communities, new collaborations between industries, and in general, the lowering of walls between traditional silos. We'll see more healthcare organizations investing in some sort of presence within online networks as more eyeballs (especially the viral type) seem to be glued there. And we'll see personal health records thrown into the mix as well, making it easy for consumers to manage it (instead of feeling like it's managing us).

How else do you think this'll all shake out?

by Christopher Cornue

The third area of focus in the Commonwealth Fund’s recent report, Bending the Curve: Options for Achieving Savings and Improving Value in US Healthcare Spending is that of Aligning Incentives with Quality and Efficiency. In the report, it is stated that our current healthcare system, based upon a fee-for-service payment structure, often rewards overutilization and inefficiency. There is wide variation of cost & quality throughout our nation, as demonstrated by the comparison of Medicare outlays per beneficiary date reported in The Dartmouth Atlas of Health Care. As comparison, this range of outlays from Medicare is as wide as $4,530 in Hawaii and $8,080 in New Jersey, yet there is no obvious quality outcome that corresponds to any increased cost. The report suggests four strategies to help better align incentives with increased quality and efficiency:

Hospital Pay for Performance – many of us are aware of the many pilot programs working to align payments for better performance, probably most significant has been the CMS & Premier demonstration project. This project attempted to reinforce actions consistent with high quality … by penalizing poor performance and rewarding superior performance, based upon comparison with a peer group. The Bending the Curve report suggests expanding this demonstration project beyond the 250 participating hospitals to all acute care under the Medicare PPS system. Additional payments would be based upon the following: 1) Top Performance at or above 90th percentile composite quality score (2% bonus payment); 2) Absolute Performance at or above 75th percentile in any clinical area (1% bonus payment); and 3) Performance Improvement for hospitals that are at 80th percentile or above for the composite quality score improvement ratio (1% bonus payment). There are further details and conditions that space in this posting prevents elaborating on.

Episode of Care Payment – the current system of reimbursement doesn’t overtly incentivize efficient or coordinated care. An alternative to the fee-for-service system is a bundled payment system covering costs of care across different settings of a patient’s episode of illness (over a determined period of time).
These bundled payments would cover episodes of care (by DRG) for all inpatient, physician and other related services. Bundled rates would also be developed for the outpatient arena for chronically ill and healthy beneficiaries.

Strengthening Primary Care and Care Coordination – this strategy is based upon the need to have primary care physicians (PCPs) take on a greater role in the delivery of care, outcomes and overall costs. Recognizing that much of the infrastructure & services (i.e., HIM, care management, etc.) needed to support these activities are poorly reimbursed, the development of Primary Care Case Management (PCCM) programs will be needed. These PCCM models (currently in some states) allow for additional reimbursement to PCPs in a “per member, per month” manner for care management services. This is in addition to the usual fee-for-service payments. Among the requirements for this additional payment would be the establishment of a formal “medical home” for the patient. Included in these “medical homes” would be enhanced services such as care coordination/management, patient education, improved access, strong IT structure, specialty referral coordination, etc.

Of final note, we see increasing efforts nationally to tie metrics to pay-for-performance. Unrelated to the Bending the Curve report are recent actions by the government to now tie reimbursement dollars to Patient Satisfaction Indicators (in 2009), and the limited reimbursement to hospitals when a patient experiences a poor outcome while an inpatient, see the following link for the Hospital-Acquired Conditions (pdf).

by Tony Chen

Fascinating article in Fast Company this month on the future of Medical Tourism. Check it out - some great pictures of their lobby & some insights/questions that all of us in the hospital business need to grapple with sooner rather than later.

A couple memorable (though maybe a little unfair) quotes from the article:

"The process will pick up speed as heavyweight for-profit U.S. hospital chains such as HCA ($26.8 billion in revenue), Tenet Healthcare ($8.8 billion), or HealthSouth ($1.7 billion) realize that hospitals such as Singapore's Parkway Group or India's Apollo chain aren't competitors so much as links in a global, offshore supply chain that can be bought and brought into the fold just as easily as a Toyota or GM plant. Medical tourism hubs will become different stops on the same assembly line: Brazil and South Africa for plastic surgery; Mexico and Hungary for dentistry; Costa Rica for a little of both; and Southeast Asia for the bodywork of heart surgery, organ transplants, and orthopedics. Patients needing new hips or hearts will be the first sent overseas by their doctors for the same reason medical tourists are headed there now: The procedures are safe, low margin, and high volume -- always the first things to go in any globalization scenario."

"The biggest losers by far would be American doctors -- especially cardiac and orthopedic surgeons -- who face the most damaging blow yet to their pride, public standing, and paychecks. In one fell swoop, they'd devolve from the rock stars of the OR to glorified mechanics, and they'd really only have themselves to blame. Overseas patients routinely return home raving about the personal attention shown by their Thai or Indian surgeons."

What do you think? Really, what can a local community hospital do about this, if anything?

by Tony Chen

A quick tangent from the world of hospitals, healthcare, HIPAA, and DRGs. I love being in healthcare, but some of you know that the birth of my son Timothy almost 2 years ago has been a life-changing, exhausting, and exhilarating experience for me. And that experience (coupled with a lot of soul-searching) led me on a mission to create a website dedicated to fuel this passion to be a great dad. Check it out at savvydaddy.com.

If you like what you see, could you help me get the word out? Email it to your friends(dad and moms!), become a fan on facebook, link to it on your blog, subscribe to the rss feed, and stalk me on twitter. And most importantly, sign up as a registered user in 30 seconds (for free!) and start commenting on articles, posting questions/stories, and enjoy! Thank you!

It was really through my experience here at Hospital Impact that I experienced the value and the power of web 2.0 to catalyze conversations and bring awareness to new areas. Don't worry - I'll still be blogging here (though no where near the 6 times/week that I used to!) Thank you for all your support, comments, and friendship here on hospital impact. Let's keep the conversations going and let's keep fighting for better hospitals.

by Tony Chen

Pretty cool stuff. Some healthcare bloggers (and some friends of the hospital impact community) are liveblogging from the World Health Care Conference through Twitter. Check them out:
Jen McCabe Gorman
A Fortin

Highlight for me so far: "We have PDD - preventative deficit disorder (AMA Definition)"

Some folks might be asking: what in the world is twitter? Think "blogging" but shorter (a couple of sentences at a time) and faster (every time you think of something good to say).

by Nick Jacobs

For a decade now, we have been bragging about Windber Medical Center’s low infection rates. The cynics simply declare that it is due to a lack of patients, but this year 153,000 patients would probably differ with you. For those who know that this rate of infection is accurate and real, our amazing housekeeping staff is given the credit. That fact is not arguable for me. They are remarkable, but I know there is more to the story.

Recently, we once again produced annual infection rates that are well below the average national rate of nine percent. In fact, they are eight percent below that figure. Although I believe that our outstanding success is due to our total and complete commitment to patient centered care, for those of you who are in need of more quantitative substantiation that is less subjective, we decided to provide that for you as well. So, we went directly to the source, our infection control specialist, Carol, and asked her to elaborate on some of the steps that she takes on a daily basis. Here is her response.

"This is a listing of just a few things that we do to assure that we keep our infection rates low. Education is the most important factor. Keeping employees informed of up to date information on infections is the primary basis of our success. Yearly education includes hand hygiene, infection control, all transmission based precautions, Methicillin Resistant Staph Aureus (MRSA), and other related updates as needed.

Counseling is provided to patients and their families on outbreaks of MRSA or other infections that occur within the home. They are given instructions, and information, and they are also free to call me with any concerns or questions. Also available are the recent documents that have been published by the Pennsylvania Hospital Health Care Cost Containment. "

In closing, if you’re initial response to this list is “we do all of that, and still have a major infection problem,” then bring in the therapy dogs, open your facility to 24 hour visits, add fresh flowers, decorative fountains, guest accommodations for care partners, fresh bread baking machines, therapeutic music and humor, massage, reiki, aroma therapy and acupuncture. It’s a Planetree thing.

by Tony Chen

There has been a lot of debate around whether these new online social communities are really value-add or just hype. I've been pondering that same question about the Hospital Impact Social Network that was started a few months ago. Frankly, I've been debating with myself on whether to pull the plug on it all together, as the conversations have been sparse.

But little did I know that this little social network was really what planted the seed that has grown up to the first Healthcare 2.0 unconference in the Netherlands. Read the thread here on how it all happened.

This is a great example of how these online connections turn into offline face-to-face "real" friends and connections. Online communities by themselves probably aren't worth too much. But when used correctly and intently, they can facilitate real-life meet-ups that otherwise may not have happened. Hats off to Jen, Maarten, and Martin for taking the initiative to reach out.

I wonder if this has implications for "patient" online communities as well. It's nice to chat/listen with others who face the same struggles with disease as you. But maybe the real value is for these communities to become localized. Online + offline. This may be where progressive hospitals can really add value.

by Nick Jacobs

Over the past two years hospital emergency departments nationally have experienced considerable increases in the number of visitors that they see. The Centers for Disease Control and Prevention reported that emergency department visits rose to an all-time high of 11 million in 2005 which is five million more visits than in 2004. Both the closure of emergency departments and the overall increase in visits have contributed to these increases.

These numbers represent about a 31% increase in visits per department across the United States, the CDC report revealed. Overall there has been, on average, about 7000 more visits per year per emergency department with the highest number of visits coming from Medicaid recipients who averaged 88 visits per 100 recipients. In other statistics there were 42 million visits from injuries yet only about 14% of the visits were from non emergent medical reasons.

This has created challenges for both physicians and staff as more resources are consumed. The stress of increased numbers has encouraged numerous physicians to resign or retire. Demands for higher compensation are also much more common. Along with this the staff also suffers from periodic bouts of burn out from dealing with both the stressed physicians and the increased numbers of patients. Sub specialists are regularly canceling or limiting their privileges, and they also are retiring, or moving onto courtesy staff positions to avoid the relentless on call duties required.

Now, in your mind's eye, try to imagine a situation where care is compromised due to these circumstances.

Another level of complication occurs for the hospitals as patient's unpaid emergency room bills have reached a new high. Many individuals using these facilities are either incapable or unwilling to pay for their care and treatment.

If you're tracking here, what you are reading about is the all too often predicted beginnings of a healthcare train wreck, a potential medical disaster. Life as we know it has already begun to change dramatically in the acute care business. Recruiting emergency room physicians and sub specialists has been a challenge for nearly five years, and we have not even begun to feel the impact of the exodus of the Boomer Doctors and staff members.

Could it be that the 47 million uninsured who are accounted for are finding no other means of receiving care? Is it possible that they do not have access to primary care physicians, to medical coverage, and have no where to turn. Is it conceivable that they allow their minor medical problems to become major problems because of these same circumstances? Maybe we should all begin to pay closer attention to the Presidential candidates and determine if their health policies are meaningful for the United States of America?

by Tony Chen

Sorry I've been MIA for a few weeks - the flu bug hit our family pretty good - from my wife to our tot to me - all in all, about 2-3 weeks. Anyway, I'm back with a few healthcare 2.0 tidbits:

- The first virtual hospital is up on SecondLife, where you can have a good experience delivering a baby. Funny, even in the virtual world, people talk about patient experience.

- More and more patient "support communities" are popping up on Second Life, including the "Heron Sanctuary" for folks with MS.

- Paul Levy, hospital CEO blogger extraordinairre, writes about his view on "friending" people and co-workers on facebook. As you might guess, Paul is all about open communication.

- Matthew Holt has a great post on what patients care about when it comes to physician ratings & info. Interesting development: Angie's list, the widely popular home repair services ratings website, is doing healthcare now, too (yeah, join the crowd). Another site Matthew points out that I wasn't aware of: TheHealthCareScoop, a social media / patient opinion site for plans/providers in MN.

by Nick Jacobs

The arts, tourism or health care; the profession didn’t matter. Volunteers have always been squarely in the center of my personal universe. No matter what the job, the challenge or the non profit profession, we have always worked very hard to create meaningful positions for volunteers. In fact, it has been our distinct pleasure to be intensely concerned with our volunteers over the years.

What have we discovered? There are virtually no boundaries, no Mission Impossible jobs, no challenges too great or too small and there is no end to what dedicated volunteers will do for any non profit organization. They need only to be empowered, encouraged and recognized. In fact, most of them will perform above and beyond the call of duty without even a nod and a smile.

The volunteer experiences that have become part of my personal history have been very unique but the essential ingredient for us has always been to be open, honest and thankful. It has been to provide them with a vision and ownership, but most importantly, it has been to embrace them as partners, as critical participants in our business, as key providers of the proverbial icing on whatever cake is being baked.

I remember once asking the father of one of my students to stand at the boy’s room and make sure that all went well there throughout an entire professional sports game where the students were performing. He never saw one minute of the game. I later found out that he was the president of a university? He had just told me to call him Frank?

Be it putting up tents in 100 degree weather, or making runs to buy the needed decorations required to top off the center pieces, we have always had people waiting in the wings to get it done. Our volunteers currently add at least 30 percent to our care giver numbers as they serve as greeters, are clowns, do hand massages, help family members, deliver communion, or sort files, our volunteers represent a bedrock element of our organization that would be impossible to replace.

Volunteers can make the difference between your patient’s happiness and comfort and their disgruntlement. They don’t have to do what they do. They do it out of commitment and caring, and your patients can feel that love, too!

by Nick Jacobs
Cell phones prohibited in our hospitals.

About five years ago, on a visit to MIT, we had a casual discussion with a physician leader, and asked why we hadn't seen signs banning cell phones. His response was fast and simple, "They don't bother anything." Ever since that visit, we lifted the ban on cell phones in our hospital, and nothing has happened to anyone.

In March 2007, Mayo Clinic researchers published the results of a study in which they attempted to deliberately create interference in medical devices through the use of cell phones. They used them near 200 different medical devices in 75 patient rooms at their facility. They also tested BlackBerry models as well. The paper published in March of '07 in the "Mayo Clinic Proceedings" says there are no "clinically imprortant interferences" when cell phones were used in a "normal" way.

According to Mayo Clinic researchers, Jeffrey Tri, Rodney Severson, Linda Hyberger, the long-held notion that they are unsafe to use in health care facilities is not valid. Three hundred tests were performed over a five-month period in 2006, without incurring a single problem.

You can look this up at www.mayoclinicproceedings.com or on Snopes.com.

Makes you wonder if cell phones are safe to use on airplanes? Maybe they're banned because the phone companies can't track you down to bill you? Any studies out there on that one?

by Nick Jacobs

After 20 years as a non medical observer in a health care setting, some of my greatest observations regarding personal change have come through my own interpretation of the results of brushes with mortality. It’s interesting how the human mind works, the depth of denial that we persuade ourselves to embrace and the creation of sometimes self-created turmoil that helps us avoid the daily realities that are occasionally too emotionally unforgiving to acknowledge.

Typically, we go on until we hit the well-known, proverbial brick wall that causes us to stop, rethink our future and make decisions as to how we should attempt to proceed.

The most extreme outcome resulting from these near death, life threatening and often life changing experiences, has been my observation as a lay medical person of primal change. So many times people have entered my life with a terminal or near terminal diagnosis, survived that illness and come back to a life that even they had never imagined. This brush with death made them realize that they were either lucky or, in fact, selected to stay a while longer and potentially make a difference. This is what I refer to as the sickness epiphany.

Don’t get me wrong. There are still plenty of us who hit the wall and happily return to the life that brought us to that event. What is that quote that is attributed to Benjamin Franklin? You know, the one that I used to think of when I practiced my trumpet for four hours a day, “The definition of insanity is doing the same thing over and over and expecting different results."

On the other hand, we have all seen the heart attack victim who, after smoking heavily for 45 years, stops cold turkey without hesitation and then tells every smoker he knows how awful the habit is for them. It is has also not been uncommon to begin a discussion with someone who had a physical scare, and then decided to quit their job or change their marital status. Finally, we have met those individuals who were barely hanging on to a spiritual thread when they faced death and found their faith. It’s the epiphany. "It came to him in an epiphany what his life's work was to be!"

Some people decide that their new found life should be spent more at home, in church or at play. We have all heard the well worn expression, “No one on their deathbed ever says I wish I had worked longer hours.” On the other hand some survivors become passionate toward causes, i.e., helping similar patients face the same situation that they survived. Still others have decided that they will take the time they have left and work to literally change the world.

It is this type of purpose driven existence that can have a phenomenal impact on all of us.

A little over three years ago, I faced death. When I realized what many people have embraced for decades, that each day was truly a gift, my initial response was, “Why me? Why was I saved?” As I searched for that why, it came to me that at least one purpose for still being here was to change the way health care is being delivered.

Co-incidentally or maybe serendipitously, another individual from a completely different background met with me today to discuss the fact that his life had taken a similar health twist. His passion, as described by him, was literally to change the way that health care is delivered.

We only have about 4500 more hospital to change in order to make this transition.