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 Nick Jacobs

As a 40ish rookie in health care management, the common conversation around the board table in the late 80's was a chorus of woeful sobs directed toward the good ole days of cost based reimbursement. That was a time when hospital CEO's could pretty much count on getting checks equal to their costs to pay for services rendered. In fact, a book entitled, The Hospital That Ate Chicago, was a good example of how hospitals could actually make a profit from the government from building projects.

Ah, to have been an Executive Director or Superintendent in that era. If you didn't golf several days a week, you were not considered competent enough to be an administrator. One of my early mentors used to say, "Son, If you want to survive and thrive in this field, you are obligated to learn to golf and play a good game of bridge."

Needless to say, I sometimes drive over a bridge, on my way back from Washington D.C.this week, I actually filled up at a Gulf station?

Today, we are seeing the beginning of an end of another era. As the tide begins to sweep the post WWII generation closer to retirement, it is clear that the System is about to change. It is about to change or die, and, once again, the ole timers will wish for better days when they actually got reimbursements that, for at least a small amount of time, would allow them to pay the bills and make a little profit for the organization.

One problem with writing a blog like this is that it's easy to criticize, easy to point out, and easy to suggest, but it will take an engaged group of hard working, deep thinking leaders to set the path for the future, a path that pays attention to the infrastructure, that will work to ensure the bridges don't collapse, the discoveries aren't curtailed, and the future becomes all that it can be. That path should be inclusive, comprehensive and for the good of mankind. Hopefully, we can help make the directional signs for that journey because, our future depends on it.

by F. Nicholas Jacobs

The rise and fall of the Cardiac surgeon as the star around which the medical universe rotates has been an interesting phenomenon to observe. In fact, three years ago when I was approached by a physician placement agency to hire a newly graduated, Ivy League trained, cardio thoracic surgeon to fill a vascular surgery position at our acute care hospital, all of my "spidey senses" kicked into action.

Why would a multi-million dollar man, a top trained, cardiac surgeon want to come to a primary care hospital for a vascular surgery assignment? It was at that very instant that I dove into heart surgery research. As the age and acuity level of our patients had continued to climb almost exponentially, heart surgeries had dropped in our area from approximately 600 to 450 to 350 a year during the previous ten year period. Then I saw the national figures that revealed a decline from a high in 1997 of 350,000 to about 250,000 coronary artery bypass surgeries in 2004.

As the recipient of six coated stents over the same ten year period, it had always been clear to me that the new, multi-million dollar men were the invasive cardiologists. Having read the latest reports on coated stents, we Boomers with six packs in our chests are nervously taking our aspirin and Plavix and waiting for that potentially fatal clot to materialize during our next stress filled situation?

I personally was a member of that very small club of 1% that had an injury to my artery ensue during my first procedure and a near fatal misfortune take place after my last invasive procedure. So much for the 1% rule. For me it’s been a 66% complication rate, two out of three procedures, but my physicians had thousands of otherwise successful procedures to their credit before and after me.

One autumn morning I overheard a conversation between a local cardiac surgeon and an Emergency Room physician. The surgeon said, "Yeah, he has 15 stents and finally wants a bypass. The problem is, it's going to take a giraffe's leg vein to bypass all of that metal." That would be another potential complication from the “full metal jacket” rule of stent implantation.

So, as it turned out, our cardiac surgeon was looking for a medically under served area where he could work to get his Green card and eventually his American citizenship, but, in general, graduating residents are having a challenge just finding the job they want. In fact, according to a recent article in USA Today, 12% of the finishing 88 cardio thoracic residents received no job offers in 2004, and that was before the bottom nearly dropped out of the open heart surgery business.

So, what do you call a heart surgeon who finishes in the last quadrant of his program? You still call him Doctor, but, to find work, he may have to specialize in lung or heart valve surgeries instead of bypass.

Maybe someday we will discover, like Dr. Dean Ornish has professed, that diet, exercise, group support and stress management will completely reverse heart disease, or maybe, like the 1973 Woody Allen movie, "Sleeper," proclaimed, it will be determined that chocolate cake, deep fried foods and smoking will be the cure. Either way, changes continue to be a reality in the world of heart disease treatment, and, until we stop lounging on our couches, over eating inappropriate food, working too many hours a day, and not practicing regular stress management program; we will continue to add to those negative statistics.

By Jared Johnson

The latest public hospital data Web site has made it to the Lone Star State, but the jury's still out about just how helpful it will be to consumers. Texas Price Point, sister to Price Point sites in at least 8 other states (IA, NH, NM, OR, UT, VA, WA, WI), is due to go live at the end of February. Most, if not all, are products of those states' hospital associations in an effort to "allow users to view and compare pricing information on common inpatient services."

I was able to take a test drive this week and it felt like I was handed the keys to the car and told to drive wherever my heart pleases. Some call this freedom or empowerment; others might say it's plain intimidating. Price Point includes median hospital charges for over 60 procedures, and they give you turn-by-turn navigation to find the ones you want.

Reaction has been mixed in other states (see Jeff Sturgeon in The Roanoke Times and Heidi Toth in The Provo Daily Herald). The following editorial from the Clinton (IA) Herald on February 1, 2007 is the best assessment I've seen:

In a free market society, it may seem ideal to let patients treat hospitals like a retail store, shopping around for the best price in order to save a buck here and there. However, medical care is much more complicated than that…

…It ought to be clear by now that this isn't the same as knowing how much a gallon of milk costs at Hy-Vee, Jewel and Fareway.

But still, Web site's [sic] like PricePoint are an important step in helping the consumer make educated choices. Health care is something everyone needs and one of the biggest headaches for the state and federal governments. The insurance business is a behemoth that sometimes appears too big for its own good, but it's the only real system we've got and can't be abandoned until a better solution is found.

The topic is confusing, to be sure, but having these conversations and exposing the many factors that boggle the mind are the best way to work toward getting everything cleared up for future generations.

I am rooting for Texas Price Point, and I hope it meets its objectives. My main question is how Joe Consumer will use this information. I can see him deluging the billing office with questions about why his charge is different than what's listed online. It opens more than a can of worms — more like a 50-gallon drum.

Still, the father of Price Point — Wisconsin Hospital Association's Stephen Brenton — pointed out to the House Ways and Means Subcommittee last summer that hospitals are doing their part to make prices available to consumers. That's one reason Price Point doesn't have to be all-inclusive. It is an effectual step toward transparency, not the ultimate answer.

Count me on the bandwagon.