by Tony Chen

2006 was the year of consumer-driven health care. Two years ago was the year of retail clinics. Last year was the year of health IT (with Google and Microsoft making big splash entries). So, what will 2009 bring? Here are some predictions sure to go wrong:

1. The number of uninsured and underinsured will increase dramatically.

Think about it: Unemployment was once close to 5 percent. At some point in 2009, it could get up to 10 percent. Add to that the many businesses that will be cutting healthcare coverage for the sake of business survival, as well as the folks who will decide to forego buying individual health insurance to make ends meet.

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by Nick Jacobs

It dawned on me the other day that several of my recent posts have been about problems, but many of them do not prescribe solutions. This one has a solution. If your doctor doesn't give you alternatives, fire him. If he or she doesn't encourage you to get a second or even third opinion, get another physician. If, as a man over 40, you have not had your prostate checked, question your physician's ability to practice. If you're a female over 40 and you are not receiving advice relative to your breast or pap exams, your physician is not doing his or her job.

Where is this coming from? Over the past twenty plus years, it has been my very bad experience to have known a number of physicians who are completely driven by finance. The goal of these physician is to do the fastest, least thorough medicine possible, just above the lawsuit level. It is their challenge each day to get as may patients through their practice as humanly possible, and skip the details. We've all known people like this, but in medicine they can be lethal.

When questioned about the percentage of patients recommended to have mammography each year from one of these practices, the reply is short and sweet. "Don't know, don't care. Takes time to write prescriptions and make arrangements. Probably less than 10% of those who need it."

When asked how much can be made by selling drugs to patients from an in-house pharmacy, though, you will receive a price quote per pill, per ounce, per patient or per hour. If there is a piece of equipment for which this physician can receive a professional fee on the property, every patient possible will be run through it as often as insurance will allow. Chest x-ray? Stress tests? Halter monitors? If it's part of the financial base, it will be part of your bill. In chiropractic they call these practitioners churners.

Somewhere along the way docs like this get off the Hippocratic path. They stop remembering what medicine is about, and many times stop caring about those people who have placed their lives in their hands. Nothing infuriates me more than a physician in a meeting who ignores three pages and three cell phone calls. It makes me ask the question, “What if that page was about someone that I loved?” These physicians usually avoid admitting patients to a hospital for even severe situations, and they are most often extremely rich.

Watch out for the signs of greed displayed by your personal physician because they are not always materially visible. Sometimes it's ownership of a lot of land, a place in Aspen, the newest Porsche, more diamond rings on their fingers than could be mined in a week; but, most often, it's a detached, cold, fast paced, business-like approach to you that makes you feel more like a widget than a person.

If you experience this, say, “Thank you doc. Please give me a copy of my medical record,” and then run like hell.

by Christopher Cornue

Unfortunately, I cannot take credit for this very accurate description of leadership in healthcare at the moment. This was a resounding theme at a recent Health Care Advisory Board meeting I attended a few weeks ago. Supporting this assertion, the Advisory Board discussed changing reimbursement methodologies, revised DRG structure later this year, global competition for paying patients, increased costs, expected growth/volume decline, shift from inpatient to outpatient, proposed legislation forcing hospitals to absorb costs for adverse events that occur during a patient’s hospitalization, a more informed consumer, increased transparency of quality outcomes for hospitals, evolution of “retail clinics,” workforce challenges, etc. No need to go through the whole list – you get the point! While many of these issues have challenged hospital leaders for several years, it’s probably safe to say that a “perfect storm” type scenario is on the horizon, whereby all of these are impacting hospitals simultaneously. Which issue do we spent the majority of our time focusing on first? How do we manage this change going forward? Regardless of our focus, I just wanted to share this “Leading Through Disruptive Change” statement, as I think it’s a perfectly appropriate label for our efforts in healthcare at the moment.

by Nick Jacobs

A few years back while listening to a presentation from Dr. Leland Kaiser, my interest was peaked when he said, "If you are not doing genomics at your hospital, you are already behind the curve." In a recent H&HN magazine article (www.hhnmag.com) by Haydn Bush entitled "Practical Genomics," the author carefully outlines the current state of the science. He quotes Lyle Berkowitz, M.D., director of clinical information systems at Northwestern Memorial Healthcare who says, "In the near future . . .physicians will be able to integrate genomic maps, or complete, individual accounts of a person's 6 billion-piece DNA code into care."

At Windber Medical Center we have been working for six years with our partners at the Windber Research Institute and Walter Reed Army Medical Center to do just that, translational medicine. We believe that the best way to rapidly improve individual patient care, outcomes, and quality of life is by translating molecular research, driven by clinical questions, into new standards of patient care. Our primary focus is improving patient care and the quality of life for the patient and their family by rapidly translating molecular and clinical research into action.

Sound good? It will be. As the article goes on to explain, "If better genetic testing for heart disease emerges, patients with increased genetic risks could conceivably undergo more regular CT scans to check on artery blockage, while also improving their diets." We have been doing this for the past five years.

The idea is for the physician to work with the patient to start a lifelong treatment of the identified risk factors. This treatment includes stress management, diet, exercise and group support. As the article states, " . . . the physician is retooled into a lifelong coach or partner to go through your entire risk report, almost as a financial adviser would manage a portfolio."

Also as pointed out by the article, let's look at the details of why we're not there just yet. First, there aren't enough genetic counselors nationwide to achieve this goal quickly. Second, most hospital information systems have no capacity to handle genomic data. Third, the fears of most patients concerning the use of genetic data to keep them from buying insurance or worse yet, from getting a job are real and definite.

Finally, there is the question of whether the patient would embrace the steps necessary to alter the potential progression of disease. In the book Change or Die the author, Alan Deutschman, discusses the reality that when cardiologists tell their patients with heart disease that they have to "change or die," nine out of ten fail to switch to healthier lifestyles. It appears as if 90% of us would knowingly select death rather than change.

So, as we push forward with our efforts to promote behavioral change through the use of integrative health through programs like the Dr. Dean Ornish Coronary Artery Disease Program, and as we work toward making translational medicine a reality through the fusing of knowledge provided by M.D's and PhD's in our labs and hospital, we work and wait for the rest of the world to understand that the future is here and the future is now.

"If you are not going genomics at your hospital, you are already behind the curve."

by Jeff McKune

In my former life in IT, I worked on a number of biotech research projects. The company organized resources around the different portions of their biotech pipeline. For each segment of the pipeline, a user steering committee was responsible for overseeing the systems and projects that affected that segment.

These committees were comprised of key stakeholders of systems at different geographical locations, project managers, and IT representatives. Even though these were IT systems, the end users had ownership, and it showed in the ratio of users to IT staff on the committees - usually three to one.

The steering committee responsibilities were fairly comprehensive. They recommended changes to systems based on their changing business needs. They reviewed and approved all changes, including those proposed by IT subgroups such as the database team or the networking team. In short, to a great extent they controlled their own destiny with regards to their operational systems.

When I joined PCRMC early in 2006, I was pleased to see the hospital beginning to use this same structure. A "user" steering committee had been organized around the management of the complexities of the revenue cycle. The committee is comprised of several department directors, as well as representatives from coding, finance, and compliance. Having the stakeholders all in one room at one time smoothes the coordination and discussion around issues that impact each of them, and it has led to significant improvements in revenue cycle efficiency.

In what other areas could steering committees be deployed in hospitals? Would it make sense to have an admissions steering committee that managed that portion of the hospital "pipeline"? In this case, the "users" would be patients - more specifically, non-hospital representatives of our patient community. What about a nursing care steering committee, or a discharge management steering committee, each with a higher ratio of patient representatives than hospital staff? Without a doubt we would gain new insights from those we serve, and the effort would bring more meaning to patient-centric care.

Perhaps your hospital is already using steering committees in this way. If so, please share your experiences with the rest of us.