In a marriage of giants, Allina Hospitals and Clinics is teaming up with MinuteClinic to coordinate care for patients and expand medical services down the road. Allina is the biggest hospital and clinic group in the Twin Cities, with 11 hospitals and 90 clinics. MinuteClinic, the pioneer of bare-bones retail kiosks staffed by nurse practitioners, has 24 locations in the Twin Cities and 500 nationwide. The deal is a sign of how far retail clinics have come, from being viewed with fear and suspicion by doctors to being essentially partners with the medical establishment. This is the second such partnership for MinuteClinic, coming after a similar deal with the Cleveland Clinic in Ohio.
Even as House Democrats yesterday revealed their version of a major overhaul to the nation's healthcare system, activists on both sides of the debate are marshaling a potent force to push their viewpoints—senior citizens. Polls have indicated that concerns about the overhaul are strongest among senior citizens, an influential bloc because people 65 and older are the most reliable voters. Their power is magnified in midterm elections because turnout is usually much lower than in presidential years. That is why America's Health Insurance Plans is spending millions to run these advertisements in 10 states.
The cases of children with H1N1 influenza jumped significantly last week, but adults will soon feel more effects from the fast-spreading flu, health officials said this week. Philadelphia Health Commissioner Donald Schwartz said the city was tracking H1N1 cases to prevent unnecessary infections and provide vaccines for those most vulnerable to the flu. The city has about 635 confirmed H1N1 cases and another nine possible cases as of Wednesday, according to the state Department of Health Web site.
In boom times, Sumner Regional Health Systems went on a buying and building spree, snapping up properties, including land near its flagship hospital here, with plans to keep expanding. Now, as part of restructuring to shore up its finances, the organization hopes to sell 20 pieces of property, including medical office buildings and vacant land with an estimated value of over $14 million. Meanwhile, the health system's top officials and a group of consultants they retained earlier this year disclosed that they're evaluating unsolicited offers from "interested parties" covering a wide range of other strategic alternatives, although no action is imminent.
The House healthcare bill presents more problems for drug makers than legislation in the Senate, but it gives the medical-device industry better breaks. The variations in the bills underscore why healthcare companies have been lobbying vigorously on Capitol Hill. Billions of dollars are at stake, depending on which version is adopted. The drug industry took a big hit in the House bill. For elderly people who are eligible for both Medicare and Medicaid, the bill mandates rebates from the drug makers so that the Medicare system ends up paying less. Those rebates are estimated to cost the industry $60 billion over a decade.
The health insurance industry is giving the new House health reform plan a thumbs-down. Karen Ignagni, president and chief executive of America's Health Insurance Plans, which represents many of the nation's insurance companies, warned in a statement that the House bill would increase costs for consumers and employers and disrupt the current healthcare system. She also painted a dire picture of the consequences of a government-run insurance plan, or public option, which is designed to compete with private insurers.
The healthcare overhaul bill produced by House Democrats would impose an array of new taxes, fees, and government mandates on major players in the health industry, including insurers, doctors, and drug and medical device makers. In most cases, the pain has been meted out with an eye toward raising the money needed to finance President Barack Obama's plan for reshaping the health system, but also with careful regard for gaining the votes that will be needed to pass a final bill. Democrats hope to vote next week on the measure, which would extend health coverage to tens of millions of Americans who don't have it, impose sweeping new restrictions on private insurers, and create a government-run insurance plan to compete against them.
Could it be that the key to good, quality healthcare is good, quality communication? Deborah Bosley, PhD, who describes her passion as making written communications simple and useful, thinks so.
"It is very clear that poor communication . . . adds to a problem of [achieving] quality healthcare," said Bosley, who is an associate professor of English at the University of North Carolina in Charlotte, and a principle in The Plain Language Group. Many of these examples of good communication can be seen in most healthcare settings every day.
To approach better quality communications, Bosley breaks it down by the three E's: effectiveness, efficiency, and economy.
Effectiveness. Many times providers may believe they are communicating effectively by giving their patients lots of oral information during a consultation—but actually they are not. A number of studies have shown that between 40% and 80% of information is almost immediately forgotten, Bosley said.
The reasons why patients fail to retain much data can vary. For instance, some patients just may not understand English that well. Others may not have good memories. Or others may get lost on some of the medical jargon used by the provider (for instance, doctors who say "myocardial infarction" instead of heart attack).
While writing down the information can help, this is not always the preferred route either. "Sometimes that information is really written so that the bureaucracy can speak to each other or that the doctor and the lab can understand it—but the patient can't understand," Bosley said.
"One of the most important things is to create information in plain language that your audience can understand and use," Bosley said. This can include taking some tips from the National Institutes of Health’s initiative on plain language that focuses on how to convey healthcare messages without speaking down to a patient.
Other times it could mean getting feedback from patients or others on written communications aimed at those patients. For instance, a flyer in a physician's office on how to dress your bandages can be made to communicate its message better by testing it out on about half a dozen people. "With 'usability testing,' you only have to test a document out on five to eight people to uncover 85% to 90% of the problems," she said.
Efficiency. "Efficiency is a problem with people having to contact a [medical] staff or physician multiple times in order to try to get clarity with the information that they've been given," Bosley said.
This has become a prime issue in discharge planning from a hospital, for example, where a patient is released from a hospital with vague or unclear healthcare data—only to return a few days later.
And in physician offices, calls from patients unclear about data or directions can eat up hours of unbillable hours of care by staff on the phones. "The lack of the use of plain language increases the inefficiency," she said.
Economy. While the most important objective in healthcare is keeping the individual alive, "the second most important thing is decreasing the costs," Bosley said. And while poor communication can negatively influence a patient's quality of life and treatment decisions, it can also impact outcomes—and possible cases of malpractice.
"If physicians and hospitals improve communications with patients, they create an environment in which patients do not want to sue their doctors," Bosley said. "If the patient trusts that the doctor has explained the diagnosis and has explained the comprehensive care that they are receiving—in a language they can understand—they are much likely less to sue," she said.
On the Capitol's west front Thursday morning, the House Democratic leadership unveiled the 1,990-page "Affordable Health Care for America Act" (HR 3962)—the bill representing the reconciled version of the healthcare reform legislation that will be going to the House floor next week.
"We are putting forth a bill that reflects our best values and addresses our greatest challenges," said House Speaker Nancy Pelosi (D-CA), who added that under the bill, 96% of Americans will be covered at a cost just under $900 billion over 10 years.
As requested, the bill is being made available "online for all to see" for at least 72 hours prior to being introduced in the House, she said. The bill melds together the three versions of HR 3200 approved by the Energy and Commerce, Ways and Means, and Education and Labor committees this past summer.
Among the bill's features are:
A public health insurance option that shall only be made available through a health insurance exchange.
Healthcare providers (including physicians and hospitals) participating in Medicare will be considered participating providers in the public health insurance option unless they opt out in a process established by the Health and Human Services Secretary.
The maximum cost sharing with respect to an individual (or family) for a year shall not exceed $5,000 for an individual (or $10,000 for a family).
Medicaid eligibility will be raised to levels 150% of the federal poverty level for all adults.
No preexisting condition exclusion period will be imposed on coverage under the program.
Insurers may not impose an aggregate dollar lifetime limit or cap with respect to benefits payable under a plan.
Children up to age 27 can be included under a parent's insurance policy.
In order to successfully prepare for the challenges of impending healthcare reform and address the effects of the extended economic downturn, many hospitals and health systems need to not only improve their operating performance, but also should consider doing so within the context of enhancing clinical integration, service and process coordination, and aligning resource utilization across the care continuum. While considerable uncertainty still exists surrounding the details of healthcare reform, certain consequences of reform are likely that hospitals will need to address.
Most reform proposals being discussed will result in significant reductions in reimbursement per case and an increase in service demand. These proposals will likely lead to further requirements to reduce costs, manage resources, and coordinate services. The table below summarizes the operational components that will require increased attention given the potential results of healthcare reform. Responding successfully to these effects of healthcare reform may well require a new approach to improving hospital operations.
Pressures to better manage costs and more effectively manage resources will most likely continue unabated. Achieving necessary improvements will require gaining efficiencies across the care delivery spectrum. Hospitals will need to develop new approaches to operational processes, structures, and service integration in order to thrive in an environment that requires them to "do more with less" in other words, survive on reimbursements resembling current Medicare rates. Operational improvement initiatives will need to incorporate elements such as clinical integration—that is, the coordination of services, information, and resources across a care continuum. Other elements that need to be included are provider relationship enhancement, fundamental process redesign (including coordination across service delivery components), new accountability and management structures and methods, and revised approaches to utilization of limited resources.
The inclusion of CI components into redesign efforts will be critical to improving operations going forward for a number of reasons:
1. Proposed healthcare reform scenarios include requirements to improve the manner in which clinical care is organized, delivered, and reimbursed across inpatient, outpatient, and ancillary service providers. Hospitals and health systems will need to provide new service models while receiving less revenue per unit.
2. Service performance, quality, and outcomes will increasingly be measured and even rewarded based on a growing standardized set of recognized metrics.
3.Cost pressures in the recent past have led many hospitals and health systems to achieve significant cost improvements in operational areas within their facilities. Additional efficiencies will be derived from improving integration and service utilization across the service delivery system and managing the resultant costs across these components.
4. Increases in the number of individuals with healthcare coverage will lead to amplified service demands (especially from currently decreased levels). This in turn will lead to a number of ripple effects:
Demand increases may occur in service lines or among payer types that do not represent optimal reimbursement levels or rates. If revenue per unit of service decreases, hospitals will need to reduce costs per unit as well.
Current clinical staffing shortages are not likely to be ameliorated in the near future. Healthcare providers will need to develop new approaches and tools to align limited resources with increased demand.
If patients cannot readily access their physician, perhaps due to potential capacity issues in physician's offices, such as was exhibited in Massachusetts, they will likely seek primary care services through a hospital's emergency department. This will exacerbate already over-crowded EDs and cause a cascade of heightened throughput issues throughout a variety of hospital functions—from ancillary areas to hotel services to patient care units. Hospitals should proactively work with referral sources to design a coordinated service continuum that considers care management, process alignment, resource utilization, information gathering and dissemination, as well as capacity management. Regardless of ED capacity issues, improved levels of care coordination and resource alignment and management will be critical for effectively addressing increased service and performance requirements.
5. Hospitals and health systems will need to consider CI requirements when improving service and resource efficiency so that related process, utilization, and organizational enhancements both improve costs and facilitate increased service coordination.
6. In order to realize operational efficiencies that factor in CI components, hospitals and health systems will be required to review their role in the care delivery system and create new models for relationships with providers across the service spectrum.
In order to ensure that CI is sufficiently considered and utilized when conducting an operations enhancement initiative, such efforts should include an evaluation of the level of utilization of key CI components:
Clinical data systems, warehouses, portals, and information availability/dissemination
Care coordination training/education for staff and key other providers
Resource management tools
Care and disease management coordination across service components
Best practice-based data (including quality indicators and core measures) used to evaluate/monitor/manage performance, identify improvement opportunities, and develop goals
Use of evidence-based medicine protocols
Alignment of financial information, incentives, and risks across care components
Clinical integration leadership and support structures
Utilization data including capacity, length-of-stay, bed turns, etc.
Cost and revenue per volume metric
Identification of improvements required to enhance clinical integration capabilities. These include:
Resources required to achieve improvements
Impacts of CI enhancements including cost/benefit
Intra-area and cross-functional components
Accountability and management structures
Once operational improvement opportunities have been identified, specific enhancements should be planned and implemented with CI in mind so that maximum efficiencies and service advancements can be realized. Feedback from providers and other stakeholders should be used to develop and institute detailed improvement plans which consider:
1. Creation of cross-functional processes that include CI components (e.g., capacity management, communication, critical paths, etc.)
2. Development of staffing and other resource utilization models across functional areas to facilitate CI (e.g., alignment of ancillary, clinical, case management, support area staffing, skill-mix adjustments, flexing models, etc.)
3. Enhancement of care and disease management functions across care components (e.g., redesign case management functions in line with clinical integration requirements, enhance roles of internal and external providers such as intensivists, mid-levels, referring physicians, etc.)
4. Integration and utilization of clinical information systems into care and management processes across service components, including standardized coding, information dissemination, hard-wiring data entry, and sharing care and decision processes.
5. Development and dissemination of key financial indicators across service components that facilitate in incentive and risk management alignment.
6. Initiation of performance measurement, monitoring, and accountability systems and structures that include CI elements and requirements that are based on standardized metrics and considered best practice standards
7. Development of CI oversight structures and integration of these functions into operations management configurations
Physician leadership
Performance management
Financial monitoring
8. Staging of all improvement initiatives to realize operational efficiencies in the context of increased service coordination and integration.
As a key component of hospital operations improvement initiatives, clinical integration should include the assessment and redesign of all key functional areas within a hospital on both an inter- and intra-departmental basis. An operations improvement initiative should focus on achieving sustainable improvements by applying leading practice methodologies to specific organizational situations and requirements, including a rigorous approach to both assessment and redesign within the context of the current economic climate, not to mention impending healthcare reform.
Optimally, content area experts with extensive best practice experience across a range of functional areas should be utilized to assess factors affecting performance as well as develop improvement opportunities specific to an organization's needs and operating environment. Most importantly, such initiatives should focus on implementing improvements that extensively incorporate clinical integration, accountability structures, and performance measurement so that improvements can be acculturated and expanded upon on a continuous basis.
Changes in the healthcare landscape going forward will challenge hospitals and healthcare organizations at every level. With an increased number of patients entering the healthcare system and an even more complex payment structure to deal with, operational efficiency will be essential to succeeding in this new environment. Well-designed and executed processes and efficient use of resources aligned with clinical integration requirements will continue to be the foundation for success. Organizations that proactively conduct a thorough assessment of their current operating performance, understand their deficits and opportunities, and engage every member of the organization in a detailed planning and implementation effort will be best positioned to navigate through the current environment and prepare for whatever systemic changes may come.
Although healthcare reform will certainly challenge every hospital's ability to deliver services efficiently, it will also reward those who have developed and realized capabilities to coordinate services, measure and manage performance, use resources wisely by matching them with demand across the care continuum, and aligning the activities of key provider stakeholders.
Frank Flosman is vice president at the Camden Group where he leads the performance improvement group. He may be reached at 312.775.1714 or fflosman@thecamdengroup.com.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
