Emerging Trends in Healthcare: Preparing for

Prepared for the Foundation of the American College of Healthcare Executives
Emerging Trends in Healthcare:
Preparing for Tomorrow Today
Presented By:
John F. Sena, PhD
©Copyright American College of Healthcare Executives 2012
John F. Sena
Professor Ohio State University
Columbus, OH 43220
John F. Sena, a professor at The Ohio State University, served for several years as the Executive
Vice-President of Healthcare Research Systems in Columbus, Ohio, a medical outcomes
measurement and marketing firm.
A successful author and lecturer, Dr. Sena has received three University-wide awards for
outstanding teaching, as well as the University's Distinguished Affirmative Action Award. Dr. Sena
also served as the Assistant Provost of the University.
In addition to publishing numerous scholarly books and over 60 essays, Dr. Sena has written three
books dealing with the workplace. From Campus to Corporation and the Next Ten Years; Transitions:
Successfully Managing Career Changes from Mid-Career to Retirement; and Work is not a FourLetter Word. Two of these books have won national awards for excellence; From Campus to
Corporation has been translated into Spanish, and Work Is Not A Four-Letter Word has been
translated into Russian and Chinese. The latter work was also chosen by a business book-of-themonth club as its monthly selection.
Dr. Sena has given hundreds of seminars on emerging trends in health care, creative thinking,
leadership skills, change management, communication and presentational skills, health care topics,
business writing, management practices, and motivation to a wide variety of organizations. He has
been a presenter for American College of Healthcare Executives for the past 18 years. He was the
chair of the National English Advisory Committee for the College Board and a writer of the English
portion of the Scholastic Aptitude Test (SAT). Dr. Sena has given presentations in 48 states and four
foreign countries.
Dr. Sena received his doctorate and master’s degrees from Princeton University.
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Name:
Program Title:
John F. Sena, PhD
Emerging Trends in Healthcare: Preparing for Tomorrow Today
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I will adhere to the ACHE policy on Conflict of Interest Disclosure. I will uphold the ACHE standard to insure
that balance, independence, objectivity and scientific rigor are maintained in the planning and presentation of
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John F. Sena
October 31, 2011
Signature
Date
Emerging Trends in American Healthcare
Preparing for Tomorrow, Today
John F. Sena, Ph.D
EMERGING TRENDS
Part One: Patient as Consumer
Part Two: Delivery Systems
Part Three: Health Care in 2020
Part Four: The Hospital
Part Five: Health Care Workforce
Part Six: Technology
2
Emerging Trends
Part One:
The Patient as Consumer
Well Educated
Demanding and Aggressive
Skeptical – “Prove It”
Technologically Sophisticated
Demand Customer Service
Choices and Control
4
Closing thoughts
“The findings of this study suggest that growing numbers of consumers want to be actively engaged. They see variance in service, quality and costs. They are comparing doctors, hospitals, medications, devices, health plans, and self‐remedies. They are exploring alternatives to conventional approaches. Consumerism is a formidable force in health care, a defining characteristic between its past and its future that will impact every stakeholder’s value proposition and business models. Consumerism is not a fad; it is a trend of enormous significance.”
5
Robert Wood Johnson Foundation has rolled out a Web‐
based state‐by‐state directory of health care providers that allows patients to access 197 state and 27 national quality databases.
CMS to expand Physician Compare to include quality‐of‐
care measurements and patient reviews.
The Commonwealth Fund has announced an update to its website, WhyNotTheBest.org. The site compares hospitals based on evidence‐based care, patient experience, readmission, mortality rates, and costs. 6
It also compares a hospital’s performance with peer organizations and national benchmarks, so that users can conduct side‐by‐side comparisons of more than 4,500 hospitals and track performance over time against benchmarks. According to Televox survey:
85% of patients think e‐mail, texting, or voice mail is as good as an office visit;
Of the 66% who received an e‐mail, text, or voice mail, 51% said they feel more valued as a patient; 34% said they feel more certain about visiting the health care provider again.
7
Major Conclusions
Health care is a consumer market;
Cost concerns are changing behaviors;
Consumers want holistic care and resources to pursue wellness;
Consumers embrace innovations that enhance self‐
care, convenience, personalization, and control of their personal health information.
They like retail medicine, e‐visits, PHRs, self‐monitoring devices. Are willing to change docs and hospitals to get better value.
8
Cleveland Clinic created MyChart, in which patients can see their medical information on line. Patients can put into their PHR information about treatments, drugs, allergies, prescriptions, information from multiple docs.
Users can request information from third parties, such as pharmacies and retail clinics, directly submitted to their PHR. Kaiser: 3,000,000 of its 8,600,000 are enrolled in its My Health Manager
VA has launched “blue button”, which allows patients to download hospital data to their PHR or other electronic media.
9
Data can be sent to a third party.
Dossia and Health Languages have partnered to produce a terminology translator to help patients understand the EMR. It translates clinical procedures and diagnoses into user‐friendly language (Information Week, 5/11).
MotherKnows PHR started last summer will give parents round‐the‐clock access to children’s medical records by smartphones or computers. See medical records, vaccination dates, medications.
10
22% treated health problem with CAM in last 12 months. In 2009, it was 19%.
17% using CAM before seeing doc; in 2009 it was 12%.
Of those who use CAM, 19% not inform doc.
10% say they prefer docs who have CAM orientation, up from 7% in 2009. Another 20% lean this way.
40% of population “open to” using alternative approach;
66% “interested” in participating in wellness program.
25% would pay more for CAM (Deloitte Survey).
Estimated $20 billion to $45 billion spent each year on CAM.
11
Generally, CAM is a result of patient demand.
CAM for Children Under 18
68% of parents say CAM is effective treatment approach;
75% want CAM and conventional medicine combined; want hospitals to have experts on both; of parents who have used CAM for children, 95% reported a positive experience (survey by Pediatric Integrative Medicine Clinical Programs, Children’s Hospitals, MN.)
41% of health care professionals use CAM (not including herbal supplements and vitamins), compared to 30% of the general population. 12
By 2010, 100% increase in CAM providers from 2002.
Two‐thirds of medical schools teach CAM
Increasing immigration and cultural diversity will swell numbers
13
According to a Kaiser study , hospitals that offer CAM get better patient satisfaction scores.
Grinnell Regional Medical Center offers wide CAM program “that improves the patient experience and improve outcomes” Patients waiting for surgery can get a 15 minute comfort message beforehand. “Ivs
go in easier, people come out of anesthesia quicker and some physicians say their patients have less pain.” Todd Linden, CEO
Linden also said CAM reduces length of stay.
14
Institute of Alternative Future (Washington, D.C.):
CAM will be integrated into conventional protocols
Integrated with preventive medicine funded by insurers
Used by conventional providers
Will provide competitive advantage to providers
Conflicting data will remind us that CAM, like mainstream medicine, is a combination of art and science
15
Why?
The Patient as Consumer
Higher Deductibles and Copays
HSA ‐‐ consumer‐driven plans. 13 million in 2010
Lower costs (under‐insured)
16
Consumer empowerment demands user‐friendly information on: Charges;
Patient’s out‐of‐pocket expenses;
Reimbursements;
Quality of care provided;
Hospital and surgical mortality, morbidity rates; Prices of physician and outpatient services;
Safety;
Physician compliance with chronic disease management;
For out‐of‐pocket costs, Central Pricing Office (conduit for physicians, payers, hospital, patients)
17
HSA and higher deductibles force patient to ask what they are getting for their money.
Value = cost divided into quality.
Spectrum Health provides quality report card on its website and prices on 1,000 procedures, mainly outpatient procedures. ProHealth Care (Wisconsin) posts prices compared to hospitals in two counties for common DRGs, quality performance ratings that are benchmarked.
18
Transparency and Health Reform:
Transparency of physician performance data to begin in 2013.
Medicare to offer 1% bonus for docs participating in Physician Quality Reporting Initiative. In 2015, docs get 1.5% cut and 2% cut in 2016 for not participating.
20% of Medicare patients re‐admitted after 30 days. Hospitals with highest re‐admission rates will have payment cuts. May prompt hospitals to do better discharge planning and work closely with nursing homes and home health agencies.
Starting in 2012, hospitals that meet five quality measures of HHS will get payment bonus.
19
CMS will recoup about $280 million in payments from 2,200 hospitals beginning in October 2012.
Wisconsin Hospital Assoc attributed coordination among hospitals, community docs, home care agencies, and nursing homes with helping about 70% of the state’s hospitals escape the new penalty.
20
HHS will track hospital‐acquired conditions and will reduce, starting in 2014, Medicare payments by 1% for hospitals in top quartile.
Starting in 2013, Medicare payments may decline by as much as 1% if hospitals fail to reach benchmarks. In first year, hospital performance will be measured in 12 areas. Medicare’s no‐pay policy for hospital‐acquired conditions will be expanded to all state Medicaid programs.
Cost‐quality index to take effect in 2015 will redistribute Medicare payments to docs based on risk‐adjusted measures of quality outcomes (AMA, Consumers Union) 21
University of Miami Medical School offers online database on doc business relationships. Physician Payments Sunshine section of Health Care Reform bill requires drug companies, medical devices makers and suppliers to report any payment of more than $10 to a doc or teaching hospital. Also includes paid speeches, board membership, drug trials. Will take effect in 2012; searchable database by Feds by 9/13.
22
Since so many patients use Facebook, Twitter, et.al.,
it is incumbent upon healthcare professionals to use these forms of communication.
More than 1,200 hospitals have a social media presence: mostly Facebook, Twitter, and You Tube.
One‐third of consumers use social media for seeking or sharing medical information. 41% say Facebook, Twitter, YouTube, and online forums influence their choice of a specific hospital or doc (PwC consulting). 57% said a hospital’s social media connections would strongly affect their decision to receive treatment at that facility (YouGov.Healthcare)
23
It facilitates communication, collaboration, conversation, and information dissemination. It provides another way of engaging the patient. By facilitating communication among groups of patients, docs, and health care professionals, Social networking is a powerful communication, educational and branding tool. One must engage consumers in two‐way conversations. 1. Incorporate humor, photos, contests, links to interesting stories.
2. Integrate your social networks: your Tweets refer back to Facebook or hospital blog.
3. Tie social media to service lines, something you are trying to promote.
24
Most hospitals now have a social media manager to handle all social media matters or to train docs and employees how to use it without placing them in legal jeopardy. Privacy remains a major problem.
Social media manager looks through social media sites to see if someone has made negative remarks about your hospital so that you may respond.
25
Additional uses of social media:
* Swedish Medical Center (Seattle) has “Sleep Up,”
an old‐night live stream of a patient with sleeping disorders, followed by Q&A.
* Lake Health (Ohio) posts ER waiting times every few hours on Twitter.
* Inova Health System (VA) puts on Facebook a 50‐
day interactive fitness and wellness program. Blog entries from football players and docs.
* Lifespan Health System (RI) uses social media for
fund raising.
26
Facebook page for awards from advocacy groups, patient satisfaction scores, doc and nurses satisfaction scores, awards to personnel.
Blog or Facebook site with weekly hospital updates (new docs, clinical trials);
27
Medscape is a social network for 100,000 docs.
Nemours, Jacksonville‐based children’s health system, used social media in creating a new hospital in Orlando.
Health care updates during a health crisis;
Mayo Clinic offers Social Health Network to help other organizations improve their social media. Oct. 2010, they formed the Mayo Clinic Center for Social Media.
Sentara Healthcare (VA) advertizes on TV that it uses social media to stay in touch with patients.
28
VA has launched a Facebook page (12/2011) for each of its 152 medical centers. In 2008, they had one Facebook page. Now 345,000 vets use them.
29
The Graying of America:
By 2030, 70 mil. Americans will be over age 65;
There are 78,000,000 Baby Boomers;
2012 more Medicare beneficiaries than people paying into the system; (social security)
Florida, West Virginia, Pennsylvania have highest percentage of people over 65
Modern Maturity largest circulation in country
One‐half of all disposable income in hands of seniors.
30
Cultural Diversity:
Three in ten people are minorities;
In 1990 census, there were five choices of racial identity offered; in 2000 census there were 63 options
Non‐Hispanic whites dropped from 76% of population in 1990 to 69% today;
By 2050, 21% of Americans will be multiracial;
Over 50% of third generation Asians and Hispanics are marrying outside of their race and ethnicity.
The “Crazy Quilt” of American society.
31
Advocate Lutheran General Hospital in Park Ridge, Il, employs a Korean NP to work with Korean patients. She prevented a false child‐abuse claim because a bruise on a baby was a “Mongolian spot” common to Asian babies. Explained to nurses why a new mother would not take a shower for one month because of a Korean belief that teeth and bones are weak after giving birth.
There is a certain type of soup that Korean mothers want after giving birth; she added it to the menu.
32
DuPage Hospital has a “Guide to Culturally Competent Health Care,” which describes for 30 cultures their communication style, family roles, and views on nutrition. (Chicago Tribune)
33
Implications:
Broader definition of patient satisfaction;
Office of Patient Relations and Patient Diversity to replace Office of Patient Relations;
Cost of care;
More money spent on chronic illnesses, esp. heart disease and arthritis;
Shortage of docs;
Need for geriatric specialists ‐‐ emphasis on functionality, depression, cog. impairment;
34
Implications (Cont.):
Implications (cont.)
Increase in home care;
Increase in telemedicine;
Increased emphasis on death and dying;
Increase in paraprofessionals; e.g. phy. assistants, home
health aides, physician extenders, therapists (2010, 83,000 PAs, twofold increase in ten years. N.Y. and CA have 7,000 each.)
Increase in geriatric centers;
Seniors as a lobby for gov. initiatives; Returning older employees;
Rapid rise in elder care, nursing homes, community care, and keeping seniors at home;
Diversity will increase among seniors;
35
Emerging Trends
Part Two:
Delivery Systems
According to Deloitte survey, 34% of people would use a retail clinic
Accessibility
Convenience
Lower Cost
Shortage of Doctors (one‐third of docs older than 55)
Rural Areas
Aging Population
Transparency (prices posted)
“Traditional care delivery models will continue to give way to alternative care delivery models, such as retail health clinics and work site clinics as health care systems battle rising costs and capacity issues…” PricewaterhouseCoopers
37
The Re‐emergence of Retail Clinics.
In 2009 and 2010 there was no growth in retail clinics. CVS closed 100; Wal‐Mart closed 50. Problem: they are slow to turn a profit. Venture capitalists are impatient.
Solution: Partnering with hospitals who may accept initial or temporary loses in favor of long‐term benefits. Name recognition important. Clinics serve as entry point for patients to hospital.
38
13% have visited a retail clinic this year and 34% said they would if cost was 50% lower than doc’s office (Deloitte)
Cleveland Clinic and Mayo have started retail medicine.
Mayo clinic in Mall of America is called “Create Your Mayo Clinic Health Experience.” “Medicine needs to adapt to peoples’ changing needs, including seeing people where they are and when it is convenient for them” (Dr. David Hayes, Medical Director).
39
Cleveland Clinic Florida has just partnered with Minute Clinics to open 15 retail clinics in Florida. CVS has 600 Minute Clinics in 24 states. Opening 45 in this year alone. MinuteClinic adds two a month in MA. Says it could double number of clinics in five years.
More than 30 million Americans are scheduled to receive expanded health coverage in 2014. Major boost to clinics which play a major role in helping the growing needs of patients.
40
Insurers are Staking their Claim
Cigna has 10 clinics;
Bravo Health in Philly and Baltimore;
Humana for people with chronic diseases (four in Florida, one in Cleveland)
Latest Trend: Combining Telemedicine and Retail Clinics.
At Rite Aid NowClinic (Detroit) a patient can choose among multiple docs from a list with background information and be seen by a monitor. No charge for talking to nurse; for doc it is $45 for 10 minutes. 41
The model has reversed 750,000 Americans went offshore in 2007
6 million offshore by 2010 (up 700%)
10 million by 2012 (Deloitte)
417,000 foreign residents traveled to US for treatment in 2007. Why Americans are going abroad for medical treatment:
Cost. $150,000 CABG in US is $10,000 in India.
Can receive comparable quality of care.
Reduced waiting time.
Internet.
42
500,000 to 700,000 uninsured can afford to travel abroad for medical services they cannot afford at home (McKinsey & Co.)
43
Quality Standards
One may select a hospital accredited by the Joint Commission International, which has accredited more than 125 facilities in 24 countries.
The International Organization of Standardization also measures quality abroad.
Money Talks
According to Deloitte, procedures abroad are 15% of what a patient would pay in US.
Prices in destination country correlate to its per capital GDP.
44
India
Liability insurance for surgeon in India is 4% of that for a surgeon in NYC.
Medical costs in India are 80% lower than US.
A good cardiac surgeon in India makes $35,00 a year.
45
Large Foreign Centers
Thailand’s Bumrungrad hospital sees tens of thousands of Americans a year; just opened new extension designed to handle 6,000 foreign patients, making it world’s biggest private clinic.
20,000 medical tourists to Korea in 2008. Korean government has partnered with LA travel agency to make arrangements easier.
Parkway Health, a Singaporean hospital chain, says foreigners make up 35‐40% of its patients. Most of their physicians trained in the US.
46
South Korea will welcome more than 150,000 medical tourists in 2012, up from 120,000 in 2011, and 82,000 in 2010. Largest and fastest‐
growing sector is plastic surgery. A section of Seoul called “Beauty Belt” has more than 200 plastic surgery clinics. 32% of South Korea’s medical tourists are from the United States.
(USA Today,12/07.2011)
47
Insurance Companies and Employers Making it Easier
Blue Cross/Shield in several states sell insurance policies that enable patients to have expensive procedures offshore.
BasicPlus Health offers members and employers option of going offshore.
Hannaford, grocery chain in New England, offers 27,000 employees option of going to Singapore, saving employee $3,000 in copays and deductibles.
48
Aetna has partnership with Singaporean hospitals.
Several insurance companies offer incentives; e.g., paying for travel and waiving deductibles.
August, 2009, Companion Global Healthcare offers insurance to its employer group clients to purchase policies to cover liability for employers offering off‐
shore health care. Has 29 hospitals in 15 countries in their network overseas; all are Joint Commission accredited. They offer concierge services for those wishing to go abroad.
49
Companion Global Healthcare provides travel assistance to any of its 29 network hospitals and three dental clinics. All network hospitals are JC accredited and provide surgery and other care at rates up to 90% less than those in the US. They provide: travel arrangements, case management services upon return, travel insurance, help with claims filing. It is anticipated that within ten years a majority of large employers’ health plans will include offshore options.
50
One type of response:
The bed lines are by an Italian purveyor of high‐
thread count sheets to popes and princes; bathroom with polished marble; panoramic view of East River, and a butler. All this for $2,400 in the penthouse floor of NY‐Presbyterian/Weill Cornell hospital. Cedars‐Sinai Medical Center in LA promises “the ultimate in pampering” in its $3,784 maternity suites.
Travel to Utah and Colorado for patients.
51
It is not a home or hospital or building. It is a treatment concept in which the full range of patient care is directed by a primary care doc who treats patients, refers them to specialists, keeps tract of who is doing what, and monitors the outcomes.
By providing a home base for patients, docs can coordinate their care, improve care, prevent unnecessary ER visits, reduce hospitalizations, lower costs.
It is a physician‐directed practice that provides care that is “accessible, continuous, comprehensive, and coordinated.” 52
Replace the “fractured” current system with one managed and coordinated by a PCP.
The goal is to provide a broad spectrum of care, both preventive and curative, and to coordinate all of the care.
Primary doc could employ a nurse practitioner, medical assistant, part‐time social worker, nutritionist, therapist. The care may include remote monitoring; information therapy, community resources, specialists, hospitals, nursing homes, and family.
53
Docs are paid by the number of patients they have, not the number of visits. The concept was started by pediatricians 40 years ago but never gained ground. Now is has been endorsed by four primary care physician societies, representing 330,000 docs, purchasers, labor, consumer organizations, and AARP. Now being tested by Medicare and Blue Cross/Shield plans.
May address shortage of physicians. A study by Group Health Cooperative said the approach led to 29% decrease in ER visits and 11% decrease in hospitalizations.
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Cost savings to come from reduced hospitalization and ER visits. Some MHs have had savings of up to $18 PM/PM. E‐visits, telephone clinical advise, case managers.
Horizon BC/BS in N.J. experienced 10% decline in cost of care per member; 26% decline in ER visits; 25% decrease in hospital readmissions.
Honest and inclusive communication among leaders and docs and among team members is essential: everyone needs to be at the table.
55
E‐visits by HealthPartners in Minneapolis has patients use a portal to send an e‐mail to the care team. On receiving the message, it is triaged and sent to the appropriate caregiver. A nurse practitioner offers immediate advice and script. Consultants in Medical Oncology is the first oncology practice to achieve NCQA recognition as a MH. They work through all phases of treatment and into survivorship. Telephone triage has allowed patients to manage symptoms in home for 75% of their calls to the practice. Chemo patients visits ER one a year, half the typical rate. Rate of hospitalization per chemo patient dropped by 43% in last five years.
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Currently, 31 million Americans receives health care through an ACO. This is 10% of the population. 250 ACOs as on Feb. 1,, 2013. 49 state have ACOs. Leading states: California 46, Florida 42, Texas 33.
Boston and L.A. have 19 apiece; Orlando has 13.
7% are in rural areas. CMS reported that more than 4 million Medicare beneficiaries are receiving care from ACOs. 27% serve Medicaid patients; 50% serve privately insured patients; 58% serve Medicare (AHA survey).
About half of ACOs are physician led. Physician‐led ACOs are smaller. Half of physician‐led, Medicare ACOs have 10,000 patients. AHA survey (2013): In 2011, 6% of hospitals responding were ACOs; mostly large systems, nonprofit, teaching hospitals.
15% in same survey had created medical homes. Survey by Commonwealth Fund: 54% of ACOs responding use some form of capitated model; numbers evenly divided between ACOs who accept global capitation with full risk and partial capitation with some risk. 58
Few ACOs using systems that predict patients that would need most services due to poor health.
Some hospitals may have waited until final rules were released in Oct. 2011. Some have a wait‐and‐see attitude.
Walgreens has partnered with three Medicare ACOs, providing screenings, wellness programs, walk‐in clinics, and medication management.
Some ACOs focus on specific diseases: Florida Blue dedicated to cancer patients; Accountable Kidney Care Collaborative.
New CMS Final Rules for ACOs (Oct. 20, 2011)
• Providers no longer at risk for any of the first three years
if they fail to achieve quality and savings targets;
• Bonuses larger. Shared savings once providers clear a savings target. Previously eligibility for shared savings was after first 2% in reduced costs;
• If patient’s doc is part of an ACO, patient is automatically included. Patient may opt out;
• Patients in ACOs are free to visit any health care provider;
• Eliminates mandatory review for antitrust issues;
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• EMR is still a measure, but provision that one‐half of providers must have meaningful use by second year is rescinded.
• “Advanced Payment Program” to help rural providers. 50 small ACO will receive upfront payments for staff and infrastructure. Will be paid back by providers in reduced Medicare costs;
• CMS to monitor 33 measures of quality performance rather than 65;
• CMS’s new estimate: Medicare to save $940 million from 2012‐2015.
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•
•
•
•
•
Crystal Balling the Future ACOs will be a game changer.
Why it may work? Hospitals and docs more integrated
than in the past; IT; Medicare creates a critical mass.
Establishing an ACO will not be as easy as the Feds have
implied.
Docs will not flock to ACOs at the start. About 40% of docs no longer have Medicare hospital‐related fee income.
Docs may not want to give up their financial independence.
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Crystal Balling the Future
• Large doc practices more likely to join than small practices.
• Providers focus on delivering value to purchasers.
63
Crystal Balling the Future • Proper alignment:
• PCPs and specialists must have a role in governance. A survey recently done by AMN (staffing and recruitment
service) of hospital administrators said that 40% of hospitals that wish to form an ACO see hospital‐physician alignment as greatest obstacle; 42% of hospitals who do not wish to form an ACO see hospital‐ physician alignment as greatest obstacle.
Who’s in charge?
How is risk shared?
How will reimbursement be calculated?
• Second greatest obstacle: cost of IT.
64
Crystal Balling the Future • Fee‐for‐service emphasizes provision of health
services by individual provider. ACOs stress coordinated teams of providers who collaborate to address patient needs.
Era of fragmented delivery of health care may be coming to an end (ACOs, medical home, bundled payments).
• Trust between docs and hospitals in a vital prerequisite (will docs trust hospital accounting?).
65
•
Crystal Balling:
May cause more hospital mergers and provider consolidation. May leave fewer independent hospitals and docs, which could drive up health costs. This raises antitrust considerations, especially in rural
areas. Federal Trade Commission and Justice Department are working on guidelines. CMS says ACOs with 50% or more of area’s market to get mandatory antitrust review.
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Providers and Payers.
Advocate Health Care (largest in Il.) partnered with Blue Cross to form an ACO in 2011. In six months reduced hospital admissions 10.6%, ER visits 5.4%. 60 case managers work with high‐risk cases.
OneCare Vermont Accountable Care Org, the nation’s first statewide ACO. It covers Vermont and New Hampshire; covers 42,000 of Vermont’s 118,000 Medicare beneficiaries.
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• Half of senior execs at hospitals are unsure about whether to participate. (Poll conducted by KPMG, 11/2011)
• 49% of specialists and PCPs said they are not ready to accept the financial risk of an ACO. (Optum Institute for Sustainable Health)
68
ACO Start‐Up Costs:
CMS $1.7 million
AHA $5.3 to 12 million
Black Book Ranking:
$500,000 for IT for small system;
4 million for large system.
• Congress will be impatient with fiscal results. 69
5% of Medicare beneficiaries consume 50% of the Medicare budget.
10% of general population consumes 70% of all health care dollars.
PHM is a group of programs targeting a defined population that uses a variety of individual, organization, and societal interventions to improve health outcomes. It is the attempt to assess and manage the health of a community.
We are shifting from a volume‐based environment to a future which will demand performance based on the delivery of value.
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PHM will pay a major role in this new paradigm and will be an integral part of future health care practices, most importantly ACOs.
Our present model is designed to address the needs of patients who are actively seeking care. It is not structured to identify, engage, and proactively address the needs of disengaged members of the population, many of whom are out of compliance with recommended care. 71
In an ACO model the health of all patients matter, even those not actively seeking care.
ACOs must identify high‐risk patients, use case management, societal intervention, educational programs, and preventive care.
The need for PHM will become even greater with an additional 32 million people being insured and the growth of senior citizens, who need chronic care management
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Current
Future (ACO, etc)
Fee‐for‐service; Value‐based
Volume based Low financial risk High accountability for
for cost of care cost of care Defines population as Defines population as patients who present at every patient in the provider
doc’s office org., regardless of whether
they present at doc’s office
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Current Future
Minimal infrastructure Must have infrastructure
(technology, staff, data) to manage the entire population
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Hospitals must have broader view of their role. You provide high‐quality of care in the hospital. You now have to try to keeping patients out of the hospital. Hospitals must have more coordination in the community, working with health departments, free clinics and other community groups. Sinai Community Institute deploys community health workers to educate asthmatic children and their parents about the condition with the goal of reducing ER visits and admissions. Also addresses the social issues which have a big impact on health.
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a. Tailor programs to individual needs through multiple modalities: Internet, tweeting, Iphone, telephone, patient portal, and printed materials.
b. Case workers, self‐management education, reaching
racially and culturally diverse populations, PHRs.
c. Special teams for high‐risk patients after discharge. You may want them to see a geriatrician, social worker, nutritionist, behavioral specialist.
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Addresses various trends:
Growing elderly population;
Growing number of chronic conditions (25% of seniors have at least 5 chronic conditions)
Fewer docs and nurses;
People living in remote areas (25% of population in rural areas. They tend to be older, sicker, and poorer);
Seniors not wishing to travel;
Cost of travel.
Patients feel connected – someone looking at their vital signs who can intervene
Enhanced compliance
Personal involvement
77
Telemedicine may be the key to long‐term success for hospitals by lowering cost and reaching a wider audience than in‐person visits. It is quickly becoming a competitive differentiator in some markets.
Mark Probst, CIO for Intermountain Healthcare in Salt Lake City: “…telehealth simply is a competitive requirement these days. I don’t see how the hospital CEO can ignore telemedicine. Busy ,tech‐savvy patients will want more user‐friendly access to healthcare and will be far more likely to use technical solutions to aid in this convenience.” Hospital and Health Networks, Dec. 2011.
78
Health Affairs (Sept. 2011) reports on a pilot in which chronically ill patients using telemedicine reduced costs 8% ‐
13% on a per patient, per quarter basis compared with patients using traditional clinic‐based care. The patients’ (heart failure, COPD, diabetes) vital signs and other metrics were recorded, and they answered health questions. Data went to a system that analyzed the data and alerted clinicians if readings were outside of normal parameters (CardiovascularBusiness (Sept. 2011).
Savings of $312 to $452 per patient, per quarter.
79
CMS says that telehealth services can quality for payment even if they’re not the direct, one‐to‐
one equivalent of an office visit. Telehealth services would only have to provide a “clinical benefit” under the new rule. Gov. Jerry Brown (CA) signed bill (10/11) to allow all licensed health care professionals to provide telehealth services.
80
Partners HealthCare in Boston reported home monitoring reduced readmission by 50% for congestive health failure patients over 10 years.
Sensor Monitoring: Monitor heart rate, respiration, blood pressure, blood oxygen, temperature, movement from sensors imbedded in wristbands.
Prisons – it is cheaper and avoids security issues (more than 3,000,000 people in prison on any given day). Using telemedcine and EMR, Texas prisons saved $1B over 10 years.
81
Difficult to find radiologists for night shifts in the ER. Hospitals are outsourcing to Bangalore, which is becoming the global center for telemedicine outsourcing. One company services over 70 US hospitals.
Telenursing:
Monitoring patients with chronic diseases, help patients manage symptoms, coordinate care for patients, prioritizing patient needs.
Allows nurses to track health patterns over time and detect deviations in data that may indicate a problem before it becomes acute. This level of surveillance isn’t possible in a traditional delivery model.
82
MetroPlus Health Plan (NYC) collects daily from homes of heart patients, weight, blood pressure, and glucose levels wirelessly and transmits them to nurses for evaluation.
Additional Benefit: When patients see their own data they begin to manage their diseases better, reduce acute care services (ER) and hospitalizations (Schlacter‐
Fairchild). Leads to self‐management of chronic conditions.
83
Geisinger used home telemonitoring program for congestive health failure patients: reduced readmission rate by 44% compared to a control group. At core of program is an interactive voice response system that asks patients questions. They have 1,000 patients using this system. Expanding it to hypertension and diabetes.
Wound care – shortage of docs and nurses. Wound Technology Network (FL‐based network of docs and AT&T) improved care and reduced costs.
84
Univ. of Nebraska matches psychiatrists with 37 rural hospitals. 89 of Nebraska’s 93 counties have shortage of mental health professionals. (VA started this 30 years ago).
Jawbone created wristband equipped with an app. that combines tracking and analysis of user movements, nutrition, and sleep patterns.
Smartheart from London connects to iPhone, BlackBerry, or Android via Bluetooth to perform electrocardiograms in 30 seconds and transmit it to a doc.
85
Univ. of Illinois has developed an ultra‐thin electronics that cling s to the skin like a temporary tattoo that can measure electrical activity from the body. Docs can now diagnose and monitor conditions like heart arrhythmia or sleep disorders. It is stretchable and flexible , can withstand twisting, poking, and pulling without breaking.
86
WellPoint has a wireless cuff for heart patients that give data to nurses on fluctuations and when heart can no longer pump enough blood.
Humana launched program in Jan.2011 that will wirelessly monitor vital signs of heart patients and, if necessary, set up a video chat with nurse.
Essensia Heart Health Failure Program uses telemedicine for COPD patients, transmitting weight and vital readings to cardiac nurse. National rates for COPD readmission after six months is 40‐50%. For Essensia, about 3%. 1.2M savings for 29 patients over six months.
87
Univ. of Arkansas has created sensors that can go into bras or underwear that measure blood pressure, respiration, temperature, and oxygen consumption. Sensors transmit data to patient’s cell phone or smartphone. When a reading is out‐of‐the‐norm, the patient is immediately alerted.
New bill introduced into the House of Rep.: 1. provide incentives for hospitals to lower readmissions with telemedicine by offering them a share of the cost savings; 2. allow ACOs to use telemedicine as an equivalent for in‐person care; 3. create new programs for remote patient monitoring for up to 10 designated conditions.
88
TELEMEDICINE’S BIGGEST PROBLEMS: THE LAW AND PAYMENT
Licensure. If a doc in NY is treating someone in Kansas, does he/she need a license to practice in Kansas? Varies by state
Must remote physicians be admitted to host’s medical staff in order to treat patients? If so, does host have to continuously monitor remote doc’s competence to same degree it does with its own medical staff?
Accreditation. Should hospitals require a certain number of procedures each year to maintain privileges? What constitutes telemedicine proficiency? What about hospitals with divergent credentialing standards?
89
Privacy. Medical records will cross state lines. Who is the ultimate custodian of the medical record? Who is responsible to ensure privacy?
Liability. Who does a patient sue for malpractice? The remote doc? The host doc? Technology firm that built and maintains the network? Which facility controls the patient’s care?
Does a doctor‐patient relationship exist with both docs or one? Does reviewing a patient’s medical record constitute a doc‐patient relationship or merely a consult between two doc?
90
NowClinic (UnitedHealth Group) connects docs and patients with “video chat.” Being introduced state‐by‐state. It will be first nationwide online care.
Hoping to reduce visits to ERs, less expensive way to give primary care. Starting in Texas: 180 counties don’t have enough docs; 79% of ER visits are for routine problems. For 45$ anyone in Texas can use NowClinic by logging on, whether he/she is insured or not.
91
Maine providers are testing e‐visits
Hope “to provide yet another way for individuals to interact with their physicians,” gives patients easier access to docs, saves time for both. Program initiated by Anthem Blue Cross/Shield
. Virtual doc visits taking place in upstate NY (fourth state).
Recent study compared conventional visits with e‐visits for acne patients. After face‐to‐face visit, patients
were given a digital camera to send pictures every six 92
weeks to dermatologists via a secure web site. Docs then gave advice and prescriptions electronically. Outcomes the same; patients and docs found it more
convenient and time‐saving; 91% said they would
do it again (4/10 Archives of Dermatology). Docs said e‐
visits could be used for diabetes and hypertension.
MDLiveCare and RingADoc (started in CA in Oct, 2010) diagnose and treat common conditions (flu, allergies) over the Internet or phone. Patients talk to a doc or nurse practitioner. Some employers offer this as part of their health care package. Objective is to avoid expense of going to doc or ER.
93
HealthPartners created Virtuwell linking docs and patients online 24/7 for minor conditions (pink eye, ear pain, skin conditions).
7% of docs use video‐chat for routine, non‐emergency and follow‐up care.
94
Go To eBay
MediBid lets providers bid to provide care for patients. Patients fill out medical questionnaire, upload their medical records, and request the procedure they need. MediBid‐affiliated docs respond by submitting competitive bids for the requested care.
Last year they did 50 knee replacement, an average of five bids per request, average price $12,000, one‐third of what insurance companies pay. 95
Emerging Trends
Part Four:
Health Care in 2020
•
The PPACA has created mega‐trends
that seem irreversible
Increasing Involvement of the feds
States used to have most control over health care (credentialing, licensing, law suits). Now more and more regs. are from the feds: Stark Law, False Claims Act, Anti‐Kickback Statute.
97
• As health care grows as the largest sector of the American economy, we can expect more scrutiny of the “business” of health care.
98
RECOVERY AUDIT CONTRACTORS (RAC)
Increased government audits and investigations.
Government gets $10 for every $1 spent on audits and investigations. It has become a source of revenue for them. Recovery Audit Contractors and your employees.
They are bounty hunters who look for irregularities.
AHA survey reported that the number of RAC‐related denials in second quarter of 2012 was up 24% from first quarter. 99
Number of medical records requests in second quarter of 2012 was up 22% compared to prior quarter. Medical records requests jumped 10% to 720,590 during fourth quarter of 2012.
Dollar value of RAC denials more than doubled in less than one year. It averaged $224.8 million in the four geographical regions the AHA tracks, compared to $185.2 million during first quarter of 2012 and $110.9 million during fourth quarter of 2011.
100
Appeals of RAC denials are difficult but have high success rate. 40% are appealing adverse rulings, and 75% are winning their appeals.
Proposed Legislation: The Medicare Audit Improvement Act would place a cap on number of documents RACs can request from hospitals to 2% of hospital claims with a maximum of 500 Additional Document Requests to a maximum of 500 ADR every 45 days. 101
The bill aims to alleviate the administrative burdens of handling medical record requests, especially for small, rural hospitals.
Payments for docs and hospitals will increasingly
be divorced from volume of care and more closely tied to outcomes. 102
MORE CONSOLIDATION OF HOSPITALS AND
DOC PRACTICES There doesn’t seem to be an option MORE CONSOLIDATION OF HOSPITALS
Hospital Leaders Magazine reported huge increase in M&A activity in 2011. Top 10 mergers represented 6.5 billion in assets, up from 3.8 billion in 2010. Trend is continuing. 103
Health care mergers (hospital mergers and doc mergers) jumped 21% in 2012 from the prior year.
There were 380 total transactions last year, up from 315 in 2011. Total transaction value was $11.96 billion (Berkery Noyes Finance).
104
In a free market, the strong compete better and become stronger, often by acquiring companies who present a threat or opportunity: Google, Apple, Facebook. This model will apply to hospitals.
• Strong hospitals will continue to do this under the guise of quality improvement and cost effectiveness.
• Will hospitals running below capacity need to consider consolidation?
•
105
• Need to have out‐of‐the‐box thinking for partnerships: large tertiary hospitals, health plans. • The growing demands on the system and a severe restriction in the funds to pay for those services will/may lead to shortages and rationing. Healthcare Insurance Exchanges will place additional service demands on health care without a corresponding growth in individual or institutional providers. 106
• These factors will lead to more consolidation of providers
into larger and larger networks in an effort to “stretch” the dollars available. This may lead to a major decline of small, private doc practices. • More exclusive payer‐provider relationships. Home Depot has exclusive contract with Cleveland Clinic for cardiac cases. CC has contracts with local hospitals for this care. More hospitals will enter into such arrangements.
107
MORE DOC CONSOLIDATION
Number of physician practices involved in M&As in 2011 increased about 20% over 2010. A majority involved hospitals buying doc practices. (Irving Levin Assoc., Health Care M&A Monthly, Nov. 2011)
Hospitals’ physician employment grew 32% from 2000 to 2010. Hospitals employ almost 20% of all physicians (AHA Hospital Statistic; Hospitals &Health News Daily).
108
76% of hospitals and health systems said they plan to employ more docs in the next one to three years.
“Physicians are seeking the stability of employment, while hospitals are seeking to align with physicians in response to health care reform, ACOs, bundled payments and integrated delivery mechanisms” (Merritt Hawkins).
109
Decline of physician independence. More and more will work for hospitals. In 2010 MGMA reported that the medical profession had reached a “tipping point” in terms of autonomy.
Collaboration models appear to have a snowball
effect; as more docs join, others are willing to consider alternatives to private practice. Payers are just as attracted to large groups of docs as they are to large hospital systems. 110
Docs must be at the center of the “re‐
engineering process” required by health reform. Docs cannot be relegated to marginal roles if they are to change their behaviors and the behaviors of others. Physician alignment will continue to be a top concern. Economic risk sharing, shared savings with payers, economic incentives, competitive benefits. 111
• Collaboration with docs becomes even more vital
to keep them on your team. Docs must be given significant role in strategic planning, growth, and operations.
• ACOs, medical homes, bundled payments require
a close working relationship between hospitals and physicians.
• As health care evolves, docs will have to be very
knowledgeable about the “business” of health care.
• Congress passed the first antitrust law in 1890, the Sherman Antitrust Law. 112
• Goals of Sherman Act are to protect competition
and to keep providers of a service “disaggregated” and to keep them competing with
each other on prices and services to better serve the public.
113
• Docs must be mindful of the Sherman Act when creating networks or when they wish to create a
large specialty group that would dominate the market for the specialty service.
• Insurance companies are largely immune from the Sherman Act (McCarron‐Ferguson Act).
• Health plans will also consolidate and acquire smaller plans, targeting those with Medicare lives.
114
PHYSICIAN LEADERSHIP WILL GROW
• Doc leadership in hospitals will grow.
• More physician and provider “activism” on political, economic, and social issues that affect health care.
In 1993, for instance, there were six MD‐MBA programs in the United States; in 2009 there were 51; in 2012 there were 64.
•
115
“The Accidental Leader”
A doc’s path to administration: he or she achieves excellent clinical outcomes, utilized resources wisely, and has earned a reputation as an excellent clinician, teacher, or researcher. These skills and abilities are not the competencies needed to lead successfully a department or organization. The newly promoted physician may lack financial, change management, communication, consensus building, forging partnerships, motivation, team building, risk management, and leadership skills. 116
Many doc activities are often done as a sole and autonomous professional. Physician leadership must ae seen as part of a larger, system‐wide change in health care that requires fundamental re‐examination of the governance structures, priorities, and professional relationships in hospitals and health care organizations. 117
Physician‐hospital relations must be strengthened, trust between them renewed, leadership opportunities made available, mutual expectations clarified, and a shared vision for the future created. Non‐clinical executives must view physician‐
leaders as partners in serving the needs of patients.
118
PCP shortages will continue to be a problem. Students may become PCPs if some of the financing of medical education is shared. Need collaborative models. Would a community fund a medical student if he/she pledged to return for a specified number of years.
Non‐physician professionals ‐‐ physician extenders, home health aides, physician assistances ‐‐ will grow drastically in number and assume many activities now done by docs.
119
In 2010, there were 83,000 PAs, twofold increase in ten years. N.Y. and CA each have 7,000 PAs.
120
COSTS WILL CONTINUE TO GROW FASTER THAN PAYMENT INCREASES
Primary drivers of inflation will remain in place:
* demographics
* consumer demand for technology
* distance between consumer and real cost of health care.
121
• Medicare and Medicaid will try to hold the line on payments in 2013.
Competition of Health Insurance Exchanges will
result in lower premiums, which will result in lower payments in 2014.
Docs offered economic incentives to reduce inpatient care, move volume to outpatient and post‐acute providers, inpatient census may decline and cause economic stress. 122
• Some experts predict that ACOs, bundled payments, medical homes, post‐acute services, palliative care will result in 5% to 10% lower use of hospitals in 2013
• Given these factors, hospitals must purse new models of care: medical homes, home monitoring, telehealth, virtual doc visits.
• Virtual‐doc visits will increase dramatically. 123
BRANDING IS VITAL
To achieve market share, the public needs to know you, prefer you, and connect with you. All means of connecting to the public must be pursued: educational, wellness, preventive programs, blogs, social medial, health care apps.
124
Emerging Trends
Part Four:
The Hospital
125
68% of hospital beds are operated by not‐for‐profit;
15% by government;
16% by for‐profit.
2,900 hospitals are not‐for‐profit.
Not‐for‐profits tax break: $12.6B ‐ $20B (Joint Commission on Taxation)
“Community benefit standard” is main source for tax exemptions. Many agendas: IRS, politicians, states, locals, associations.
126
August, 2011, Illinois Dept. of Revenue denied three hospitals their property tax exemptions. They averaged 1.3% of revenue for charity.
In 2010, Provena Covenant in Urbana had its nonprofit status revoked.
Gov. Cuomo has established (Aug. 2011) a taskforce to examine compensation of hospital leaders. If found excessive, money must be returned to the state.
“How much money that hospitals receive from the state and tax benefits is going to good works and how much is going to the salary of top executives” (Benjamin Lawsky, taskforce chair).
127
Exemption from local property taxes is single largest contributor to the value of tax exemption.
In 2005, school district in Beachwood, Ohio, challenged Cleveland Clinic’s medical building’s tax exempt status and won.
128
According to GAO, almost impossible to measure community benefits because “measurement of community benefits for federal purposes is still largely a matter of individual hospital discretion.”
“Bad Debt” and “Medicare Shortfalls” are two major problems. If “community benefits” includes bad debt and Medicare shortfalls, hospitals in Indiana and Texas would double their community benefits total.
Schedule H of Form 990, says bad‐debt and Medicare shortfalls should not be reported as community benefit beginning in 2009. CHA and AHA agree to let data be collected, analyzed, and conclusions drawn.
129
Grassley, Cath. Health Assoc., and Voluntary Hospital Association (VHA) have formed guidelines for community benefits:
Report charity care at cost, not charges;
Report unpaid costs of government programs, such as Medicaid;
Exclude bad debt from charity care costs;
Exclude Medicare shortfall from charity care.
AHA believes that bad debt and Medicare shortfalls should be counted.
130
Interim Report by the IRS, March 2010
• IRS found that no uniform definition of “uncompensated care” emerged from their survey;
• “The lack of consistency or uniformity in classifying and reporting uncompensated care and various types of community benefits makes it difficult to assess whether a hospital is in compliance with the current law” (Dir. of IRS Exempt Organizations).
131
Be aware of state case law. If charitable services are 1% of gross revenues, community benefits are not adequate. Feds have not specified a percentage.
IRS study:
* 20% of hospitals reported benefits spending of less than 2% of revenue;
* 60% of hospitals spent less than 5% of revenues;
* Spending 3%‐7% of total revenues on community benefits and charitable care is likely adequate.
132
You are at risk if:
* Only a very small number of patients are
provided free or discounted care;
* Dollar value of free care is minimal;
* Unpaid bills are immediately referred to collections;
* Uninsured are charged hospital’s full rates;
* Failure to publicize Medicare and Medicaid services and indigent patient policies; * Failure to allocate surplus revenue to research,
education, and medical training;
133
* Hospital does not promote health for the benefit of the community;
* Hospital does not retain sufficient control over
physician practices to ensure that community benefit is provided throughout the organization.
* “Private inurement”: when an individual receives excessive, disproportionate benefits or compensation;
* “Excess benefits transaction”: excessive, non‐
fair‐market compensation. 134
Patient Protection and Affordable Care Act
Requirements:
* Have written financial assistance and emergency care policies publicized;
* Avoid abusive billing and collection practices;
* Limit charges for patients eligible for financial assistance;
* Provide community health needs assessment report to IRS for tax years beginning after March 23, 2012.
135
* Failure of an individual hospital or physician practice which is part of a hospital system to meet PPACA tax‐exemption requirements could affect the tax‐exempt status of the entire hospital system.
Hospital boards may consider establishing a community benefits committee to do research and set standards for their hospitals for providing charity care.
136
Committing up front to a fixed price with the potential to share savings that result from efficient care has been found to be highly effective in previous bundled payment demonstrations.
Physicians in pilots reduced length of stay and testing and increased use of generic drugs. Patients expressed greater satisfaction than at non‐demonstration sites.
Docs and hospitals paid after treatment was completed. Predetermined quality safeguards; e.g., in‐hospital infections, readmissions due to incomplete treatment. Rationale: docs and hospitals work efficiently together when paid together.
137
Johns Hopkins Hospital has entered into a bundled
payment arrangement with Pepsi. Pepsi employees, 250,000, will have co‐pays and deductibles waived should they enter this program. (Baltimore Sun, 12/11)
• Centers for Medicare and Medicaid Innovation (CMMI) just announced the national expansion of bundled payment pilots. 138
• Some Concerns:
• Provide everything patients need and nothing they don’t. Will docs have the discipline required to follow current best‐practices and commit to providing only the tests and procedures that patients need? How to balance that idea with the demands of the patient and the litigious nature of health care. 139
•
•
•
•
•
•
•
Some Concerns:
Do hospitals know their true costs?
Hospitals must be able to assess risks and set payments according to those risks. Hospitals must be able to assume role of payer. Probably work best with large, integrated systems.
Probably work best with acute care.
Will hospitals use fewer specialists to keep costs down?
Will docs and hospitals skimp on care?
Will hospitals distribute payments to docs fairly?
140
Palliative care is specialized medical care for people with serious illnesses; it focuses on providing relief from symptoms, pain, and stress. It is provided by a team of docs and nurses who work with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age. They may receive curative treatment. PCPs might not have the resources to handle.
At Dana‐Farber Cancer Institute, palliative care combined with curative program had better patient morale, lower costs, and 2.7 month longer survival compared to non‐palliative care patients. Palliative care also reduces ER visits and readmissions. 141
66% of all providers had palliative care teams in place in 2008, a four‐fold increase since 2000.
Palliative care is the huge cost of cancer drugs and other treatments for relieving terminally ill patients in the last months of life.
Young docs are fueling the push.
These programs aren’t just good for patient care and satisfaction; it’s good for business also. Univ of Rochester Medical Center found palliative care in 2007 save 1,400 ICU patient days at an average of $450 a day. 92% of seriously ill patients said they would consider palliative care; 92% felt it is important to make such services available. 142
Palliative care is not to be confused with hospice care. Hospice is a form of palliative care limited to the dying.
Futurescan Survey:
To be accredited, will hospitals need to have quality pallaitive care teams ‐‐ 26% very likely, 47% somewhat likely.
ACOs and integrated care systems that do not have quality palliative care services (not only in hospitals) will be seen as deficient – 34% very likely, 48% somewhat likely.
79% think that by 2018 medical schools and residency programs will require palliative care training. 143
According to Agency for Healthcare Research and Quality report, Kaiser’s home‐based palliative care program increased patient satisfaction, reduced ER visits and readmissions. Palliative care team: doc, nurse, social worker, chaplain provided support and education to
patient and family.
Cleveland Clinic created first palliative care program 25 years ago and works across multiple settings: home, hospital, outpatient clinic, nursing home. 144
“We believe people want to stay functional in their homes. It’s not only better for the patient but also is cheaper for healthcare. It’s relatively low‐tech and low‐
cost care” (Bernard Hammes, Dir. Respecting Choices).
Access to palliative care for is an important approach to preventing unnecessary hospitalizations among the
sickest and costliest patients.
145
Hospitals generate 2 million tons of solid waste per year – 15 pounds of waste per patient every day.
Hospitals expend twice as much energy per square foot as a commercial building.
Survey of hospital executives:
• By 2015 hospitals will have to report incidents of environmental harm;
By 2015, 90% of hospitals will conduct environmental audits, up from 39% today;
• By 2015, 90% of hospitals will have a “green team,”
compared to 33% today (FutureScan 2010)
146
Some Best Practices:
Virginia Mason Medical Center’s cafeteria has no garbage cans. 100% of cafeteria’s waste is recycled. Compost 750 lbs of food each day, saving 4,000 gals. of water each day from disposals.
Swedish Medical Center (WA) eliminated blood pressure monitors containing 180 pounds of mercury.
Children’s Hospital and Medical Center (WA) recycled more than 40 tons of computer monitors in 2008. Compost food, saving about $8,000 a year on water.
147
Six healthcare organizations have partnered to form the Healthier Hospitals Initiative (9/10). Long‐term goal is to decrease environment‐
related sickness, generate environmental benefits, including green purchasing and building, reducing energy. They have produced the Healthier Hospitals Agenda for distribution.
148
The Problem:
44,000‐98,000 patients die in hospitals yearly as result of patient safety (To Err is Human). Goal was to cut number in half in 5 years. Recent reports indicate death toll from medical injury, approaches 200,000 a year (Hearst News, 08.09.09). 43,600 deaths from automobile accidents (2006);
90,000 from poisoning, firearms, and falls combined.
In Nov. 2010, patient data from 10 randomly selected hospitals in NC found that over a five year period no change in patient harm.
Every hour, 10 people die national‐wide in hospitals due to avoidable errors; another 50 disabled; 149
The Problem:
Pneumonia and sepsis (blood infection) killed 48,000 patients and cost $8.1 billion in 2006 (Reuters, 2/22/2010) ;
Study of 69 million patents from 1998‐2006, indicated that patients who developed sepsis after surgery had to stay in hospital 11 days extra at a cost of $32,000 per patient. Approximately 20% of them died (Reuters, 2/22/2010) in the hospital.
Sepsis is the leading preventable cause of death in hospitals.
CDC says hospitalizations for sepsis doubled in last eight years. 150
In a pilot conducted by UCSF, nine Bay area hospitals reduced mortality from sepsis by 40%, dropping sepsis mortality rate from 27.7% to 16.6%.
Steps:
1. Educate staff. Make everyone aware there is a problem;
2. Identify and screen high‐risk patients, especially in ER;
3. Adhere to protocols; 4. Use antibiotics sooner when necessary.
151
• Univ. of San Francisco’s nurse leadership program reduced sepsis by 54% in one year by having nurses screen all new patients and at the start of each shift. If nurses see two signs of sepsis, they start a fast‐
track program of treatment and monitor patients during each shift.
• Quality improvement practice in Michigan reduced bloodstream infections and saved $1.1 M a year per hospital. Each central line bloodstream infection costs $36,500 to treat. Patient safety program costs $3,375 per patient. Basis of program is cockpit‐style checklist and education. (American Journal of Medical Quality, Sept. 2011)
• Feds estimate that 180,000 Medicare recipients die each year from hospital mistakes. 152
Report by Inspector General Daniel Levison, HHS:
“Hospitals may investigate preventable injuries and infections but practices are rarely changed to prevent them in the future. Hospital employees report only one in seven errors, accidents, and events that harm Medicare patients.” Independent docs reviewed patients’ records and estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in one month. Hospitals under report patient harm because they are unclear about what patient harm is and what should be reported. Hospitals should create a list of “reportable events” and how they should be reported. (New York Times, 01/06/12)
153
Need for More Intensivists
Average patient in an ICU suffers 1.7 potentially life‐
threatening errors each day. 50,000 die annually in the ICU from preventable causes. Intensivists reduced mortality by 15% to 60% compared to ICUs with no intensivists (“The Future of Tele‐ICUs” medgadget.com 06/2011).
154
Possible Solutions:
HHS launched $1 billion safety initiative (2011). Hopes to save 60,000 lives over three years and save $50 M in Medicare costs over next decade.
Require states to report medical errors. Only 20 states do this, and hospitals often to not report cases.
Public should know about unsafe conditions. 45 states do not provide hospital‐specific data.
National data bank of preventable medical errors.
Sully Sullenberger says use aviation practices: national patient‐safety reporting system, use of checklists, creation of industry‐wide culture of safety.
John Nance, “Why Hospitals Should Fly”
155
In 2011, CMS added patient safety to its Hospital Compare web site to track hospital‐acquired conditions and infections.
Efforts to reduce interruptions for nurses handing out medications resulted in an 88% drop in errors at nine San Francisco Bay area hospitals. Alert others when giving out drugs by wearing bright vests or sashes. (San Francisco Chronicle 10/28/09)
156
NY legislature to pass bill prohibiting neck ties on anyone in a clinical area, jewelry, wearing uniforms outside of the hospital. Hospitals to provide more scrubs, abandon long white coats, education to staff.
NY study concluded doc’s ties harbored eight times more pathogens than security personnel wearing ties.
Recent study found that 65% of nurses’ uniforms had pathogens, including 21 that were drug resistant; 60% of docs’ uniforms had pathogens (American Journal of Infection Control, 8/11)
157
Union Interest in Hospitals /Politics
Employee Free Choice Act (EFCA)
sign a card the union exists
no secret ballot
employer violations of labor laws have much higher fines than in the past.
National Labor Relations Board:
New chair is Wilma Liebman. Some of her statements:
1. Protect workers’ rights to collective bargaining, the cornerstone of our economy and democracy;
2. Make it easier for form unions through majority sign‐up;
3. Prevent discrimination against union supporters in hiring.
Union membership among nurses, lab technologists, physician assistants, and other health care professionals increased by 10.4% in 2007 (Bureau of Labor Statistics)
158
In 2005, the Service Employees International Union named health care as a priority. In 2007, the union said it would consolidate its 30 health care locals (1,000,000 membership) into a single union.
Mary Kay Henry, new head of SEIU, was named “Top 23 Women in Healthcare” by Modern Healthcare and says
emphasis will be on local organizing.
13.5% of technical and professional health care workers were union members in 2007.
159
Wages were 11% higher for union members compared to those not represented by a union.
Dec., 2009, a new national union of nurses was formed, National Nurses United, with 154,000 members. It united the California Nurses Association, Massachusetts Nurses Assoc., and United American Nurses.
Recent (8/11) court case ruled that nursing assistants in a facility in Mobile, AL, could form their own union without other nursing home employees (Specialty Health Care Case).
160
Exit Interviews of Employees Joining Unions
Management and managers didn’t listen;
Greater voice in patient care;
Lack of engagement and direction – not telling me where we are going and my role in getting there;
Wages
Some Preventive Measures:
Importance of managers and front‐line supervisors;
Listen to needs of employees;
Do a union vulnerability survey
Create Employee Advisory Groups ‐‐ conduit from employees to management about needs and concerns.
161
Emerging Trends
Part Five:
The Health Care Workforce
Heath care added 8,000 jobs in Nov. 2012, despite Sandy.
Health care jobs stand at 14.18 million; this time last year, it was 13.84 million.
Hospitals’ physician employment grew 32% from 2000 to 2010. Hospitals employ almost 20% of all physicians (AHA Hospital Statistic; Hospitals &Health News Daily)
163
It is predicted (Bipartisan Policy Center) that we shall see the following changes in job growth by 2018:
Registered nurses to grow by 22.2%;
LPNs and licensed vocational nurses to grow by 20.7%;
Home health aides to grow by 50%;
Nursing aids, orderlies, attendants to grow by 18.8%;
Physicians and surgeons to grow by 21.8%
“One‐third of the fastest growing occupations are related to health care, reflecting increases in demand as the population ages” (Bureau of Labor Statistics).
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The Problem:
Shortage of PCPs in 2025 ‐‐ 35,000‐40,000
1980s‐mid‐90s, medical schools put cap on enrollments believing managed care would produce glut of docs.
Enrollment was 16,000 a year
Population grew by 70 million
78,000 Baby Boomers
Women physicians work 25% fewer hours
Average medical student in 2008 had debt of $140,000
Preference to become specialists (avg. PCP in 2008 earned $175,000. Ave. radiology earned $400,000).
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Some Possible Solutions:
Accredited med. schools increased by 4 in 2010 to 130.
Grants for PCP education (AMA is supporting programs to decrease debt by scholarships and loan repayment).
Grants for docs who stay in state.
Cap on malpractice payments.
9% increase in medical students specializing in family medicine in 2010, compared to a 7% drop in 2009 (Amer. Academy of Family Physicians). 76% of hospitals and health systems said they plan to employ more docs in the next one to three years.
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Why we need more nurses? Aging population and aging nurses.
55% of RNs projected to retire from 2011‐2020;
“What we see now is an aging workforce. Many nurses in their 50s will be retiring soon. There is a silver tsunami retirement coming” (VP of Nursing, Johns Hopkins, 6/6/11).
Average age of nursing educators is 55. Shortage of RNs could reach 500,000 by 2025;
According to HHS, RN shortage to grow from 8% in 2009 to 12% in 2010 to 29% in 2020. That’s 808,000 too few nurses in 2020.
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30,000 additional nurses annually to meet nation’s need, an expansion of over 30% from current graduation rates (Univ. of Penn. Study)
In 2003, enrollment up by 16.6%
In 2006‐07, enrollment up by 4.9%
30,000 qualified candidates turned away in 2007; 67,000 turned away in 2010 (American Assoc. of Colleges of Nursing). At Univ. of Minnesota, 64 of 324 applicants accepted; Univ. of Pittsburgh, 120 of 1,050 accepted this year.
UNC reduced nursing program by 25% this year because of cuts in state funding, which meant faculty layoffs (Washington Times, 6/6/11).
Reason: lack of nursing faculty and classroom seats. 168
The Problem:
Bureau of Labor Statistics projects that by 2012, we need 69,000 more medical technologists and 68,000 more medical technicians than we had in 2002.
Decrease in their numbers greater compared to other health professionals;
Average lab professional is almost 50;
Lack of advancement impedes recruitment and retention;
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The Problem (Cont.):
Professional lack of visibility.
$32 M public‐private partnership in CA to boost number of medical technicians, technologists. 25 community colleges to enroll additional 700 allied health workers in classes. State needs 206,000 more in next six years.
Vanderbilt Medical Center has pulled staffers from other parts of the hospital to work in the labs.
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Emerging Trends
Part Six:
Technology
Costs to Increase: Health Expenditures as a % of GNP
1993
2002
13.80%
15.40%
2003
15.80%
2004
16%
2005
16.20%
2006
2010
2015
16.50%
18%
20%
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Health Care Spending in 2012
About $2.7 trillion. Spending in 2012: 18.1% of GDP
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EMR
Fewer than 2% of acute care hospitals have comprehensive EMR;
Between 8 and 12% have a basic EMR system (NEJM). Cost to feds for every hospital to have EMR: $100 billion. Ultrahigh‐Field‐Strength MRI.
Robotic Systems for Surgery and Endovascular Catheterization. Prostatectomy, valve replacement, hysterectomy, coronary bypass. Residents being trained in it.
Costly; The science has outpaced clinical evidence for improved outcomes and cost‐effectiveness.
May want to buy specialty‐specific robotics
(orthopedic).
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Proton Radiation Therapy.
It has been in existence for years but it now getting more attention.
Costly: 20 million (4 or 5 times more than traditional technology; high operating costs).
Reimbursed for only a few clinical applications.
CMS considered it as one of its top 10 priorities for 2010, will be looking at evidence of efficacy. If CMS reimburses, private insurers may also.
Radio‐Frequency Identification Technology. 175
Therapeutic Hypothermia After Health Attack or Stroke.
Rapidly cooling patients’ temperatures using a special intravenously administered slurry, according to clinical studies, contain and prevent damage to heart and brain.
Miami, Boston, Houston, Seattle, and NYC require ambulance drivers responding to myocardial infarction to take patients to hospitals that offer therapeutic hypothermia.
Rapid Tests for Deadly Infections.
Need for tests that give results in 2 hours. How will this fit into your infection‐control protocols? CMS will not pay for hospital‐acquired infections.
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Health Information Exchanges (HIE) to share information with patients and other health care providers.
Point‐of‐care Technologies – mobile devices connected to wireless network, voice‐activated systems;
Smartphones with abundant memory and large screen can delivery critical information for immediate use; use
of Iphone and Blackberry for better communication;
Telemedicine.
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Error Prevention – possibly 80%
Eliminate 200,000 adverse drug interactions.
70% of medication mistakes are errors in prescribing –
57% of them could be avoided by CPOE (Agency for Healthcare Research and Quality)
Used mostly in teaching or government hospitals.
Meaningful Use has been a boon to CPOE. MU demands that hospitals use CPOE for ordering at least 30% of medications. Before MU, about 87 hospitals a year adopted CPOE. Now the average is 233 a year.
15.7% of hospitals had them in 2009; 21.7% in 2010. (KLAS market report)
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Sentara Health (Norfolk) reduced ICU mortality 27%, Length of stay by 17%, Saved $2,150 per patient, Increased nursing satisfaction
St. Mary’s Health (Jefferson City, MO), uses eICU: Mortality rate dropped by 24% in one year; Cardiac arrests dropped 69%; LOS fell by 14%. They use intensivists and critical care nurses. Nationally only one in five ICUs has an intensivist on staff.
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Remote 24‐hour monitoring of critically ill patients from a command center staffed by intensive care specialists could save 350 lives and $122 million a year if all Massachusetts hospitals adopted the model. Analysis of state’s only tele‐ICU found that it reduced ICU mortality by 20% and saved insurers $10,000 per patient.
About 250 hospitals are now using eICU to connect rural patients with specialists.
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Bottom Line: RFID tags can be used in every area of health care. They are one of the least expensive and potentially one of the most transformative devices in health care technology.
10% to 15% of health care organizations are using RTLS. 95% of them cite operation efficiency gains. (KLAS report)
Locate patients and staff;
Measure patient waiting times;
Less walking in hospital for nurses;
Monitoring patient transfers;
Inventories;
Infection control.
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Locating medical devises or equipment that is critically needed but in short supply. Increase utilization.
Remove bottlenecks.
Increased accuracy of charges
To reduce bacteria‐related infections, Univ. of Miami Jackson hospital has RFID sensors next to soap dispensing machines that read badges and record who, when, and where washing occurred.
St. Mary’s Medical Center puts RFIDs in sponges, gauze, and towels to be sure they are not left in patients.
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Univ. of North Carolina hospitals use RFID to prevent surgical items from being left in patient.
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There are about 1,000 robots in hospitals. WSJ predicts that 10 times that number could be in service in 5 years. Many will do menial jobs. Aethon’s TUG robot is a 500‐pound device that delivers food trays, supplies, and more in 100 hospitals. It uses GPS and motion sensors to stay out of the way of people. Saves the cost of six full‐time employees. 184
Jackson Memorial Hospital in Jackson, Florida, uses a joystick‐operated, stethoscope‐equipped robot named Chico (Computer Hospital Intensive Care Operator).
Docs can examine patients, speak to them, access files, and diagnose. Army is also testing Chico.
Archives of Surgery compared robots making rounds with docs making rounds for 270 urology patients. No difference in outcomes.
South Miami Hospital: 19 surgeons performed 1,000 robotic surgeries in 2011.
Intuitive Surgical: 70% of all prostatectomies in US done by robot.
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Cooley Dickinson Hospital performs hysterectomies by robots that are orders of magnitude more precise and less invasive than human‐performed operations.
EDGAR (Educated Doctor Guided Assisting Robot) is 5 feet tall and lives at Grande Honde Hosp. in Oregon.
Controlled by a laptop computer and joystick, it can roam on its wheels transmitting to a doc or nurse who may be miles away. Has high resolution zoon capabilities, flexible neck, camera eye, telephone for conversations, printer for generating prescriptions. It can send echocardiograms to remote cardiologists and images of skin to dermatologists. 186
I Robot’s Roomba and Aethons robots can clean hospital facilities;
Carnegie Mellon developing robots to relieve nurses from serving food. They also created ROBOT‐X, which they sold to McKesson, that is in 400+ hospitals and has dispensed half a billion medications.
Robots allow remote doc to see (including the retina), hear, and talk to patients.
Univ. of Colorado using robots to mix chemotherapy drugs. Brigham and Women’s, Univ. of Pennsylvania, Univ. of Massachusetts are doing the same, hoping to eliminate human error and protect technicians. 187
McKesson is distributing this technology which is currently being used in Europe. Robot can read chemo orders, mix different drugs in precise proportions, deposits them in IV bags or syringes, drops used vials into waste container.
Robots perform safety checks. They weigh drugs before and after they’re mixed to confirm dosage, check bar codes to be sure it’s correct drug. To double check, robot places drug on platform, rotates it 360 degrees, takes images of drug and compares them to stored images.
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A robotic device just developed (Nov. 2012) can make eye procedures easier and more precise. The robot can filter out hand tremors and can protect fragile parts of eye by entering the eye in the same exact spot.
Henry Ford Hospital uses robotic surgery for oral cancer patients. Robot’s long, thin arms allow docs to see more clearly and work inside mouth and throat with greater ease.
Univ. San Francisco Medical Center uses robots to fill pharmacy orders. No errors in 350,000 medications in phase‐in period.
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Japan has about one‐half of world’s industrial robots.
Mitsubishi recently developed a robot that recognizes up to 10 faces and understands 10,000 words. Honda has developed one that can walk while holding a person’s hand and carry objects on a cart.
The Bottom Line
Robots are more sophisticated, complex, and useful than ever before. They can do some jobs better, faster, cheaper, and safer than humans. They may be able to address shortage of professionals to deal with elderly population. We need to develop plans for using them.
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Mobile health technologies are mainstream
The Perfect Storm: cultural change among docs, outstanding technology, cost‐effective.
More than 80% of docs have smartphones – up from 64% in 2009. Will be used for patient care, admin functions like charge capture, and continuing education. IPhone is most popular among docs (Manhattan Research).
30% of docs use IPad for EMRs, view radiology images, and communication with patients (Manhattan Research).
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“Band‐Aid‐like” sensors that continuously transmit readings wirelessly to mobile phones;
HealthPAL , a mini‐cell phone, links to various telemetric devices and patient monitors by Bluetooth;
Intel’s Mobile Therapy is on a smartphone, which allows a therapist to keep track of a patient between sessions. Patient can indicate personal feelings on a “mood map,” as well as indicate energy level, sleep habits, and level of stress. Therapeutic exercises can be 192
sent immediately to patient.
Transmit fetal monitoring to doc at remote site.
myLoyola Select (Loyola Univ. Health System) has an app that lets patients view their current meds, make appointments, view test results, allergies, and preventive‐care guidelines over their iPhone or iPad.
Measuring heart health. A user can hold finger up to the camera’s lens to measure blood flow, heart rhythm, respiration rate, and blood‐oxygen content.
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Technology that allows sodium and blood oxygen levels to be monitored via an iPhone and nanosensor “tattoo” will soon be announced. A solution containing certain nanoparticles is injected into the skin. They fluoresce when exposed to glucose and sodium. A modified iPhone is pressed to the skin and tacks changes in the level of fluorescence.
AT&T has developed smart medicine bottles that use light and sound to remind patients to take pills. Also sends text and phone alerts when bottles are unopened.
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We have smartphones that can see, feel, and hear. Soon we will have ones that the smell. Researchers in Belgium are developing sensors for smartphones that can replace a human’s olfactory sense. Docs could smell for infections.
Stanford Univ. developing an app. that shines a fluorescent light into one’s mouth and take a picture with SmartPhone. Malignant tumors show up as dark spots.
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FDA has just approved a glucose monitoring app.
that attached to iPhones and iPods for diabetes monitoring.
Heart monitor app. turns an iPod into an electrocardiogram device. Patients holds it in hand or on chest to detect irregular rhythms. Can analyze, transmit, and store ECG readings. On market in Sept., 2012. 196
Crawl, Walk, and Run
What is it? A giant mesh of interconnected computers working together. Rationale for Hospital Adoption: Shifting allocations from a limited budget and limited human resources away from lower‐value, back‐office operations in favor of higher‐value clinical and patient services.
The cloud may do this by (1) providing economies of scale by offering shared IT resources, by (2) providing turnkey access to state‐of‐the‐art applications and by (3) reducing IT staff.
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Three types of cloud computing:
1. Public Cloud. The deployment of a public cloud is open to a largely unrestricted universe of potential users; it is targeted not to a single enterprise. 2. Private Cloud. They are designed for access restricted to a single organization and are used as an internal shared resource. It offers the user a greater degree of control and security.
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3. Hybrid. A portion of the infrastructure is deployed in the service provider’s cloud and a portion is at the customer’s premise. Combines the speed and cost‐
savings of the public cloud with the security and control of the private cloud. Offers flexibility: certain workloads can be moved rapidly and easily from public to private or vice versa.
79% of providers want private cloud (survey 2010).
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Athenahealth is in process of building an HIE that manages patient information and administrative data in a cloud. “We need to start talking about a HIE as a verb rather than a noun. Physicians … can perform tasks using an online network that can help them realize cost savings and efficiencies rather than depending on phone and fax transmissions (Athenaleath spokesperson). 200
Google and Microsoft offer cloud systems that require
very little additional software for current computers.
A boon to small practices. No need to increase infrastructure. Save space.
Software upgrades and maintenance are outsourced to the cloud. ACOs and Medical Homes demand information to be shared quickly. Hospitals won’t have to ramp up their infrastructures.
Predictability: cloud providers bound to deliver specific results at a specific monthly cost based on usage. Security: information is encrypted.
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Vivek Kundra, Federal Chief Technology Officer, is asking the DOD, VA, and HHS to turn to cloud computing
(Government Health IT, 5/23/11).
A KLAS survey of hospitals and docs found that 55% have something in the cloud, from clinical apps to picture archiving to communication systems to EMRs. 202
Another aspect of coordinated care. It helps to break down the silos. HIE is the secure, electronic exchange of health
information among people and organizations in the health care community to drive efficient, high‐quality care. In theory HIE improves patient care and reduces costs by fostering collaboration and lowering administrative costs.
Survey of 200 hospital executives by Beacon Partners:
Nearly 70% of hospitals are building or planning to build the infrastructure for HIEs. Many respondents
were concerned about high startup costs and lack of capital to invest in them. 203
Two‐thirds saw an HIE as a “positive move” for their organization; 42% said it would improve patient outcomes. Most important reason for having HIE: patient safety and fewer medical errors. Brigham and Women’s and Mass General cut lab orders by 53% by accessing EMRs through HIE.
Other goals: increased availability of patient data across care settings, increased communication among practices, reduction in redundant tests, coordinated care by exchange of clinical information and data with non‐
affiliated practices. 204
83% of hospitals either have or plan to participate in an HIE project.
95% of providers expect to be included in at least one HIE interface by mid‐2012.
80% of providers expect organizational HIE budgets to significantly increase by 2014. (survey by Black Book Rankings)
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