In the last month, I've seen two how-not-to-get-screwed-by-hospital-bills articles.

This one from a Florida Newspaper is written towards seniors who have a hard time deciphering their hospital bill. They quote a startling stat (anyone know where this is from?): hospital billing errors result in patients overpaying by $1,300 on average. Aside from the typical talk about duplicate billing and length of stay, if all else fails - they recommend hiring a billing advocate that charge $30-$150/hour or a commission on the savings.

I saw a very similar article in at biz yahoo on the 8 most common hospital billing errors.

While many hospitals are still in the stone age on making their bills patient-friendly, some hospitals are taking the lead with on-line bill pay and easier-to-understand bills. Read this article from hfm and if you haven't already, visit HFMA's Patient Friendly Billing Project for resources, tools, and insights.

In the last HFM magazine, I saw a very insightful article on why hospital registration clerks need to build relationships with patients.

I think we all already know the benefit for doctors and nurses that establish relationships - more job satisfaction and less lawsuits.

This article takes that a step further to the registration clerk. Why does s/he have to be all friendly, especially to self-pay patients? This isn't about being chummy, but about truly understanding the patient's financial situation. This results in better classification of the patient (bed debt vs. charity care) and sometimes this leads to discovery that the patient is eligible for Medicaid or SCHIP.

As CDHP is on the rise and as hospitals continue to focus on the front end of the revenue cycle, this could be the end of the $9/hour registration clerk. This front-line employee will have more sophistication around revenue cycle, customer service, and even financial planning?

Not a big deal, but maybe the start of a notable trend? Memorial Healthcare System in Florida decided it was worth it to make their entire website available in Spanish. Using TransMotion technology from MotionPoint, the new spanish website will more effectively reach out to the large Hispanic communities - in Miami-Dade, Hispanics make up almost half the population.

Props to MotionPoint, which only truly entered the hospital market in July 2005, by partnering with MedSeek. Just a few months after that partership was announced, scoring just a reputable 6-facility system ain't too shabby. It seems like a superior technology.

The things that come to mind:
- Seems like only hospitals in high-Hispanic population areas (and world-class hospitals) will consider this. However, with hispanic population in the US at 14% (40MM or so) and growing fast, more and more hospitals will be considering this.
- Now that Memorial has a great spanish website, the easy part is done - do they have spanish-speaking registration personnel, nurses, and physicians to back it up?
- It's a fairly well-known fact that the uninsured rate for Hispanics is much higher than some other demographics. So how will increased volume pay for the investment in the website? Or is this viewed as a "community benefit?" (apparently so)
- While we're on the topic of language, the NY health chief is updating her state's regulations to ensure non-English speaking patients get the proper care (and privacy)

So, for my "milestone" birthday this past weekend, my wife took me to Boston & Cape Cod (and surprised me with the presence of some great friends). I also got to visit Fenway Park for the 1st time, which brought back memories of last season's thrilling and stressful run. I couldn't even watch those games last year - it was too stressful for me. Being riled up for hours at a time couldn't have been good for my heart.

Well, according to some stats from local ERs in Boston, watching the Red Sox was potentially dangerous for other reasons, too. Turns out ER visits in 6 Boston hospitals were down ~15% while Boston was in the playoffs last year - lots of people who normally would make the visit stayed glued to their TVs.

I'm still not sure why Red Nova, a science & space website, continues (to pay) to put up these interesting articles on the uninsured, hospital management, the healthcare sector, etc.

In this article, they highlight a state policy difference between Arizona and Florida. Arizona has effectively reduced its uninsured rate from 24.5% to 17% in seven years by putting in $$ to expand health insurance, getting docs to agree to provide discounts, and letting county & local officials develop discount programs.

In the same time period, Florida's uninsured rate went from 17% to 19%.

what the article doesn't address is how did AZ pay for this?

A couple of hospitals in Nashville are finding new revenue streams from... Temper-pedic, and maybe even a soft drink company pushing its water and juices.

Started in July 2005, The Enliven Partnership is pushing the envelop by selling category-exclusive sponsorships to companies who can enhance the patient experience. Hospitals get free products and funds, sponsors get product placements.

Before we dismiss this idea too quickly, read enliven's 2-page PDF that explains their approach - they are obviously also being very sensitive to the overcommercialization/those-capitalist-pigs gut reaction that many of us will have. This could truly be a win-win-win situation:
- Anxious patients get a better experience
- Cash-strapped hospitals get cash and valuable products.
- Vendors get branding

So long as the products truly fit the hospital mission of serving patients better, why not?

Are you an starving artist with no health insurance?

At Woodhull hospital in Brooklyn, no worries! Instead of paying, you can teach pediatric patients how to make sock puppets. That was the experience of Betsy Kelleher, a teaching artist at the Henry Street Settlement in NYC. As this "bartering" program is relatively unique, her story has been getting a lot of attention lately.

will we see more "will work for healthcare" type of arrangements?

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All of this while more unnerving news on the uninsured appeared last week:
- King County (Seattle) has a 10-year high uninsured rate of 15.5%. Furthermore, for Latinos is was 35.5% (!!) and for African-Americans is was 21.5%. (and not surprising there's more uninsured in the city of Seattle versus the suburbs)
- In Arkansas, the uninsured rate is 17%. For Hispanics, it may be as high as 50%.
- In a weird twist of irony, for these uninsured, it took a hurricane for them to get some much-needed medical care.

MCOL has launched a new consumer-driven healthcare website, www.consumerdrivencare.com</a>, for consumer and professionals in the industry. The only thing about this site that I don't like is that I wish I came out with it first - it's about time someone put together a "portal" of sorts for consumers to get this kind of information. True, the info is still light, but they have collected numerous relevant articles and provided advice to consumers.

But for a professional in the industry, the most intriguing part was their stats:
- Enrollment (graph) is up to ~3 million
- The marketshare (graph) leader is Uniprise with 30% of the market. Not surprisingly, Uniprise is a branch of mega-monster UnitedHealth.

9/11 and now Katrina. Hospitals have been spending millions upon millions in the past few years on emergency preparedness: a greater stockpile of diesel to run generators, 72 hours worth of supplies always on hand, security and communications upgrades, etc.

But as this report from Boston shows, many of the country's hospitals are unprepared. As such, JCAHO announced a guide for less affluent hospitals to be prepared. Included in this checklist are things like: safeguarding important data, finding appropriate corporate partners in the community, and linking with mental health agencies/resources. Also, check out the Hospital Association of the Greater New York Area - they have successfully linked their areas hospitals so that resources can be redirected quickly in times of emergency. This may very well be a model for the nation.

The hospital CEO position is probably one of the toughest positions in healthcare, and maybe anywhere. As passionate as I am about healthcare, I honestly do not aspire to this spot.

A few weeks ago, I highlighted the CEO of Detroit Medical Center, who has aggressively turned his hospital around.

A couple of recent hospital CEO interviews in the press recently. Here's one with Desert Springs Hospital CEO, Sandy Kaufman, who talks about the success of their partnerships and service line expansions.

Here's one with Lawrence Hospital CEO, Edward Dinan, who talks about his faith and his "best practices" in hope.

Last year, ACHE put out a very interesting piece (PDF) on CEO/CNO relationships, based on a survey of 1,000 CEOs and 776 CNOs. Among the findings: CEO/CNO relationships are good and CNOs get a lot less board exposure than CFOs.

Also from ACHE, they have been tracking hospital CEO turnover for almost 15 years - the avg turnover for the last 4 or 5 years: ~15% (1 in 7 or 8 hospitals changes CEOs every year!). New on the ACHE site is CEO turnover by state. The highest: Nevada (33%). The lowest: New Hampshire (3%). Strange that there is such a high variance - if you assume that these rates correlate with financial performance, one would speculate that state policy has a big impact on hospital performance?

And finally, since the Modern Healthcare survey on hospital CEO pay, as expected there has been some of criticism and defense. Some of that fun in Pittsburgh and Georgia (pdf).

A heart-warming and good-business move in Atlanta. Shepherd Center decided to purchase the Hawthorne Suites Hotel next door. They'll renovate the place so that patient families can stay temporarily for free. Given that Shepherd specializes in paralyzing spinal cord and brain injuries, the typical stay was 6-8 weeks anyway. Since they had already been providing free temporary housing for 30 days, this increases their flexibility for extending that time and may even reduce their overall costs.

A new RAND report suggested that computerized medical records will save the nation $81B - that's $77B in improved efficiencies, and $4B in less errors. (RAND press release here)

What I'm still trying to understand is why RAND didn't use the Bush Administration's cost estimates of $150B + $50B annual maintenance. And I can't quite figure out all their assumptions. Nonetheless, If they did use the $150B/$50B for costs, that means EHR would pay for itself in about 5-6 years ($81B - $50B = $31B in true savings/year) - remember that's 5 or 6 years after it is completely implemented - not great, but not bad either.

Now if we could just get people to agree on universal standards.

The government's hospital compare website added three more quality measures (2 involve preventing surgical infections and 1 on pneumonia) to its previous 14.

Here's a graph that I pulled up for two local hospitals, Evanston Northwestern and Northwestern Memorial (apparently, they haven't submitted this data yet):

Also, now that the site has been up for almost 5 months (launched April 1st, of all days), 70% of hospitals are now submitting data.

Apparently, bad debt has more or less stabilized in Tennessee hospitals this year. Hospitals are getting better at managing the process, but higher premiums, more high-premium plans counterbalance that.

Some useful stats:
- Community Health Sys: 10% bad debt
- HCA 8.9% (after providing more aggressive discounts to underinsured)
- Industry as a whole: 10.1%

Still, some hospitals continue to blame bad debt for their financial woes, like this one in Indiana. This hospital has simply doubled its aid program, effecting taking $ from the bad debt bucket to the charity care bucket. These 2 hospitals in Idaho are increasing their educational outreach towards self-pay patients, especially the federal CHIP program for kids.

Back in business school, one of the most amazing statistics that I learned was that organizational culture was the primary culprit in derailing 1/3 of all corporate mergers. 1/3! I was surprised that such a "soft, fluffy" thing could become such a huge factor. But it did make sense - it's why so many mergers look so enticing on paper, but end up failing so miserably.

My previous boss always used to say, "Management is in charge of really only 2 things: culture and structure." Since he didn't have an MBA at the time (and I did), I thought I'd inform him: what about strategy? competitive intelligence? what about strategic planning? He just kinda smiled and I thought I had him. But upon further reflection, I'm realizing that maybe he's right. All of those things are important, but they end up falling under structure and/or culture - i.e. strategy & intelligence & planning have to be built into the organization.

And now, thinking about hospitals - when you look at the 100,000 or so deaths that happen as a result of accidents, how many of those are really a product of a poor organizational culture? Aren't many of these errors really a result of people not communicating or people fearing the wrong things? These are org culture fundamentals, aren't they?

When we look at some of the best books written on leadership and hospital management, strangely, they take a disproportionate amount of space to address organizational culture. For example, the series I did on If Disney Ran Your Hospital was primarily about reloading the culture. Hardwiring Excellence by Quint Studer spends a lot of time trying to help you create a success-breeds-success culture. When MBA students study the success of Southwest Airlines, they come to the conclusion that "culture" is their source of competitive advantage - it's unique, it's lasting, and others can't copy it.

So why doesn't anyone in healthcare talk about this more? Especially as the tidal wave of consumerism bring more change, how much more will we have to be organizational culture architects?

Consumer Reports and Health Improvement Institute have launched a beta site for comparing consumer health websites: healthratings.org

Two things I find particularly impressive:
(1) The site provides strengths AND weaknesses for each site. For example, for WebMD, weaknesses mentioned include: "busy with distracting advertising; poor visual representation of pages."
(2) The site attempts to objective rank each website along 9 dimensions (e.g.identity, ease of use, design, coverage, etc). Maybe I'm just a sucker for harvey ball graphics.

By the way, the only hospital to make the top 20 is Mayo Clinic.

Is there a day coming when such a site would exist for hospital websites?

Versant, an interesting non-profit, is tackling nurse retention from an unique angle: providing an "RN Residency" program at your hospital. A quote from their website:

"Unable to handle the intense pressure and resultant stress, new nurses leave their first employment situations at alarmingly high rates in the first 12 –24 months of service; new graduate RN turnover currently runs between 35-60% within the first 12 months of employment"

So far 700 nurses from 13 hospitals have graduated from the program.

If you haven't already, check out MedScape's blog - numerous nurses tell their front line stories in the aftermath of Katrina. Some memorable quotes:

"The looks on some of the faces of these people will probably haunt me for the rest of my life. I already see these people in my dreams. The cries of the residents (and even some of the staff) when they are told they have nothing left to go back to and that we do not know if their families have made it, are sometimes too much to handle."

"Not one person I spoke to had on their own clothes; they were grateful for the donations. It was overwhelming and for the most part seemed unbearable, but every time I looked up to take a deep breath, the outpouring of love and humanity I witnessed gave me strength to move on to the next cot, holding the next person."

"My [8-year-old] daughter provided much-needed assistance by running paperwork back and forth to order medications or to bring me supplies. I watched her facial expressions as she gently placed stickers on the patients signaling that they had been seen by the nurse, always making eye contact and always with a smile. I knew that her life was changed forever, for the better."

Also, check out the story of this 113-bed mobile hospital.

A little under the radar screen, Intel re-orged in January 2005 into 5 units, with healthcare (now called the Digital Health Group) as one of them.

Louis Burns, a home-grown-Intel-exec and now chief of Digital Health at Intel, gave a speech a few weeks ago. What I thought was interesting:
- He made it clear that they're in it for the $$, not for "altruism"
- He eluded to the fact that they will go after home health before hospitals (is this a pilot strategy or just more closely aligned to their tech?)
- They're already working with some tech design for 3,000 hospitals in China

Burns also showed off some wireless therapy systems.

Book Review: Healing Words by Dr. Michael Woods
(4 of out 5)
An impassioned and thoughtful plea from a doctor to doctors to say "I'm Sorry"

Given all that has been recently reported on physicians saying "I'm sorry," this short, straightforward book couldn't have come at a better time. Dr. Michael Woods has written a practical, motivational book directed at physicians on the why's, how's, and what's of apologizing to patients. Drawing from personal experience, stories from other doctors, examples from other industries, and research data, Dr. Woods does not hold back in making an impassioned plea for physicians to master this tricky part of the patient-doctor relationship.

At ~82 pages, you can probably read this book in one or two sittings (In fact, I read most of it in the waiting room as I waited to see my doctor. Luckily he didn't have to apologize for anything that day). Dr. Woods moves quickly from topic to topic, breaking down just about every psychological, cultural, and emotional aspect of "I'm sorry" - why it's so difficult for physicians in particular to apologize, what a meaningful apology entails, what the patient is thinking/feeling in apology-worthy situations, how to build more authentic relationships with patients, and even what exact words you could say in difficult situations. He even advises to apologize for: "(1) being late for a scheduled appointment; (2) receiving a patient complaint about poor service from hospital or office staff; and (3) Interrupting a patient who is speaking - even if you must take an emergency call."

Overall, doctors should apologize appropriately (and probably more often)- it's the right thing to do, it's the compassionate thing to do, and if that's not enough, it might even prevent some lawsuits.

Definitely this is a book written by a doctor for doctors. For the admin readers, something to read and then pass along to your clinical leadership (and risk management dept).

I'm just sorry that I didn't read this book sooner.

As most of you have seen, a lot has been written recently on the "the power of apology" from physicians. This is an overdue & healthy development that could make a huge impact. It's a shame that it took data "that it pays to be honest" to get people's attention. But hey, regardless, this is better for the patient, better for the physician, and better for our healthcare system.

Tune in tomorrow for a book review of "Healing Words: the Power of Apology in Medicine" by Dr. Michael Woods. For today, here's a summary of what I've seen:

Physician Apology in the blogoshere:
The very prolific Kevin M.D. has posted numerous times on physician apology, but most relate to the fact that apologies actually decrease malpractice and politicians who realize its value are trying to make it less risky for physicians to do so. Red State Moron laments that sorry shouldn't be the hardest word and quotes from a popular (and highly-linked-to) article from the National Review. Dr. Tony reports that even Harvard's teaching hospitals is considering a sweeping disclosure policy, including training in apologizing. StraightFromTheDoc (I told you he is prolific) points to a case when admission of a tragic mistake led to increased quality and reduced medical error in a Boston hospital OB-GYN area.

Physician Apology in the press:
Sorry Works!, of course, has been getting tons of coverage: from Time Magazine, the New Hampshire Union Leader, the Boston Globe, the St. Louis Post, and the Chicago Tribune, to name a few.

Also, there is the now-infamous op-ed piece (reg required) in the NYT by Dr. Richard Friedman. His closing line: "In the end, most patients will forgive their doctor for an error of the head, but rarely for one of the heart." Another memorable quote: "Patients sometimes spontaneously improve despite incompetent treatment. On the other hand, a patient who receives exemplary medical care may fare badly simply because the illness is hard to treat. In other words, doctors are often praised or blamed, when the outcome is in fact a chance event."

Here's some interesting data from one malpractice insurer in Denver: "Average payments to aggrieved patients were under $6,000, compared with about $284,000 for doctors not in the program." For more eye-opening examples/stats, check out this article in RedNova.

AHA launched a new site Hospital Relief Efforts - other hospitals around the nation can use this site to offer up personnal and supplies. (Hat tip: MSSP Nexus)

I was quite excited this week when I was contacted by Andrew Barna, a hospital executive over in San Jose, CA. He just started a hospital-admin focused blog, called healthcare tomorrow. He's off to a great start with an entries on HSAs, what's right on healthcare, and (my personal favorite) the long-term potential impact of JCAHO.

Andrew - welcome to the hospital admin blogosphere! Look forward to more insights now that the JCAHOites have left the building.

Most hospitals are prepared for some emergency, but this was just too much. Read this NYT article for an inside look into how area hospitals are coping. No electricity means: diagnosing infections with your sense of smell, manual pumping of airbags for pulmonary cases, and trying not to get stung by pesky insects. Still, there's plenty of canned ravioli, peanut butter, and corn flakes to go around. A couple of hospitals remain open:

Biloxi Medical Center, the only one in Biloxi.

Oschner is still open, too

To the staff and administration of these hospitals, thank you for sticking around to serve your communities.