Some of the highest value hospital care actually may be provided by nearby community-based hospitals, according to the 2009-2010 Hospital Value Index released Tuesday that ranks hospitals by an analysis using publically available data on quality, affordability, efficiency, and patient satisfaction performance data.
"What's interesting when you run studies of this kind [is that the hospitals] are not always who you think they might be. They're not always the big brand. They're often a community hospital that's serving a smaller rural or even a suburban market," said John Morrow, a senior advisor to Nashville-based Data Advantage, a privately held health information company, which created the index. "They are not a single model of healthcare, but they shine the light so others may follow."
Of the more than 4,500 hospitals that were analyzed by the company, 747 were identified as providing "best in value" care. The company noted that if all hospitals across the country performed at the average benchmark for the "best in value" hospitals, about 9.3% of costs—or approximately $60 billion—could be eliminated from annual hospital spending.
With the inclusion of many community hospitals, the analysis suggests that consumers may find higher values closer to home and that policymakers may want to expand their search for models of reform beyond the bigger name teaching hospitals, according to Morrow.
The highest ranked hospitals in the study were found to be geographically diverse—with the top 10 hospitals located in Dothan, AL; Minden, LA; Tawas City, MI; Clarksburg, WV; Gastonia, NC; Maysville, KY; Elmira, NY; Mechanicsville, VA; Holland, MI; and Winston-Salem, NC.
Among the 100 largest metropolitan areas, the highest ranked markets are Charlotte, NC; Rochester, NY; Grand Rapids, MI; Pittsburgh, PA; and Knoxville, TN. Hospitals in larger cities, such as Los Angeles, San Francisco, and Chicago were found to score lower, based on the index. Overall, markets with a population of less than 2 million people were found to outperformed markets with a population of more than 2 million.
The top five states in delivering value were:
North Dakota
Iowa
Montana
South Dakota
Maine
The bottom five states were:
New Mexico
Arkansas
California
Hawaii
Nevada
California had only two hospitals among the top 100 "best in value" hospitals, while New York, Alabama, and Iowa each have at least six hospitals in the top 100.
As legislators consider healthcare reform, it will become important to recognize and reward those hospitals that deliver outstanding value, Morrow said. But the idea of value has to be more clearly defined—with hospitals wanting to know the areas in which improvements are needed.
The Centers for Medicare and Medicaid Services (CMS) did recommend the use of value-based purchasing in November 2007, in which hospitals would be reimbursed based on the overall value that they deliver. But the agency has not officially established what value-based purchasing will look like, said Data Advantage CEO Hal Andrews.
The company is trying to expand on some of those concepts by looking at metrics CMS already uses:
Quality, by examining data that includes CMS' core measures, patient safety, mortality, and readmission rates.
Efficiency, by including the relative measure of the cost to the hospital for providing services.
Affordability, by providing a relative comparison of prices charged for inpatient and outpatient services, including what hospitals ultimately collect.
Patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems, which is better known as HCAHPS.
While the data may show that a community hospital or a large academic teaching hospital may be providing excellent value for the care they provide, the report does not include information about what they are doing "to deliver a higher level of value care than other hospitals," Morrow said.
"We don't think there's really enough to know what the commonalities are," said Morrow, who said the company is organizing a summit in December to look at the issue.
"There are examples in every category [of hospitals] that are doing well, and it's easy to demonstrate that they are doing well. And we think that instead of looking to one or two hospitals that are either geographic or demographic flukes in the overall scheme of things—that we look to the top quartile performers and say: What's going on that works in Billings, MT, as well as in Nashville, TN, as well in Worcester, MA," Morrow said.
Hospitals themselves, as well as consumers, can look at hospital-specific and market-specific data by visiting the free Web site and selecting a hospital found on the map.
So it's important for people, especially politicians, to know what the typical provider on the frontlines of medicine thinks about the current healthcare debate, and the public option that seems to be so divisive.
Two New York researchers realized that evidence documenting how most physicians are leaning on this crucial issue is lacking.
So they decided to close the knowledge gap. They created a survey and sent it out starting in June to a randomly selected list of some 5,000 physicians culled from the roster of the American Medical Association. They received responses back from 43.2%.
The physicians were asked which of three proposals that would expand health insurance coverage they most strongly supported:
A mix of public and private options, in which people younger than age 65 would have a choice between enrolling in a new public health insurance plan like Medicare or purchasing private plans
Private options only, in which the government would provide low-income people with tax credits or subsidies so they could buy private insurance without creating a new public plan
A public option only, similar to a single-payer system, in which no one buys private insurance and everyone is covered through a plan like Medicare.
The answer? 62.9% supported the first option. Their survey, by Salomeh Keyhani, MD, MPH, and Alex Federman, MD, was published in Monday's online edition of The New England Journal of Medicine.
"Respondents—across all demographic subgroups, specialties, practice locations, and practice types—showed majority support (>57.4%) for the inclusion of a public option," Keyhani and Federman wrote.
So did physicians in every census region, with percentages ranging in favor from 589% in the South to 69.7% in the Northeast. Practice owners and those who don't own practices supported a mix of public and private options.
Physicians practicing in both rural areas and urban settings favored number 1 as well, a mix of public and private options.
Primary care doctors were the most likely to support a public option (65.2%).
Doctors in other specialty groups, such as radiologists, anesthesiologists, and nuclear medicine specialists who have less direct contact with patients "were the least likely to support a public option, though 57.4% did so."
Even 62.2% of those who identified themselves as AMA members, which two months ago voiced strong opposition to a public option, said they supported it.
As a bonus question, the researchers also asked physicians for their views on whether Medicare should be expanded to people between age 55 and 64, such as the Senate Finance Committee has proposed. More than 58% supported the expansion.
"The support was consistent across all four specialty groups (primary care providers, medical specialists or subspecialists, surgeons or surgical subspecialists, and all other doctors) with proportions in favor ranging from 55.6% to 62.4%."
Yes, there are lots of questions to be answered about how such a public/private health insurance offering would work, how it would meld with a pay or play rule, an insurance exchange or an individual mandate.
But as Keyhani and Federman wrote, large groups of organized medicine have been the ones to influence healthcare policy over the years, "and in doing so may have often obscured the collective views of individual physicians across the spectrum of specialties interests and regional affiliations."
"Our study of a national sample of physicians showed that a clear majority support a combined public-private approach to expanding health insurance," they wrote.
"It seems clear that the majority of U.S. physicians support using both public and private insurance options to expand coverage," the authors wrote. "Therefore (it) should be carefully considered by lawmakers as they finalize legislation to reform healthcare and provide coverage for 47 million uninsured Americans."
It is not by coincidence, to be sure, that the study was released on the eve of the unveiling of the Senate Finance Committee's health reform package, a massive bill that does not contain provisions for a public option.
The Obama administration's online health reform strategy is falling short for consumers who are increasingly are turning to the Internet for health reform information. The White House's newly created "Reality Check" Web site is designed to address misinformation about its health reform plans, but Internet users are unlikely to find the site when conducting the most popular health-related online searches, according to experts.
There will be 18 million U.S. adults who access Twitter on any platform at least monthly in 2009, a 200% increase over 2008 levels. Usage will reach 26 million U.S. adults next year, a further 44.4% climb. This forecast counts 11.1% of Internet users as Twitter users this year, a figure close in line with Harris Interactive and Pew Internet & American Life Project estimates of 13% and 11%, respectively, in spring 2009.
Dana-Farber Cancer Institute in Boston has one year left on its $1 billion Mission Possible capital campaign, the largest effort the organization has undertaken in its 63-year history. And instead of waiting for the last year to solicit employees, the organization approached senior faculty before the campaign's 2007 public launch. The development professionals explained the campaign's significance and four key funding areas, and even before the public campaign launched 96% of the senior faculty committed to a gift.
When St. Joseph's Healthcare System redesigned its logo it could have simply swapped out the old for the new organization-wide. But the hospital decided to literally put the icing on the cake by hiring a celebrity chef to incorporate the hospital's new logo into a designer cake and displaying it at an event documented by a TLC reality show.
The focal point of the logo—a yellow biplane—is folded into many elements of the rebranding campaign the Paterson, NJ, hospital launched in March. The hospital's marketing team worked with the Wilmington, DE, ad agency Aloysius Butler & Clark to create the campaign in the hopes of becoming the dominant provider in Northern New Jersey.
"Our goal was to get across the fact that now we're a fully integrated system and push out who we are to the community," says Nancy Collins, director of public relations and marketing at St. Joseph's. "We wanted to focus on who we are as an organization, our mission, our vision, and our values."
Before it launched the campaign, the 1,000-bed health system worked to improve its services so that when they launched the campaign the message they sent would match the care patients experience.
The next step for the marketing teams was to create a tagline. They chose "inspired care." That tagline was included in all of the campaign elements, including print, digital, billboards, flyers, and brochures.
"We're trying to shape perception and increase awareness," says Collins. "The inspired care tag to me really captures the uniqueness that is St. Joseph's."
The digital campaign launched on June 9, targeting active searchers who were interested in learning more about stroke recovery and surgery. By June 30, their Web site (www.StJosephsHealth.org) had received 227,485 impressions and 218 unique site visitors. Visitors spent an average of 1 minute and 26 seconds on the site.
In this month's HealthLeaders magazine cover story, I wrote about the patient of the future. From adopting (and adapting to) new technologies to building better doctor-patient relationships to making it easier for patients to get information about their health to making it easier for them to book appointments, the predictions in the article all have one thing in common: They improve the patient experience.
The changes may also make life easier for physicians, specialists, and other healthcare professionals. They might even save hospitals and physician practices money. They might increase market share. They might give your brand and reputation a boost. They might get you some ink in the local papers.
But the bottom line is that it's not about you. In the future, it's all about the patient and how he or she experiences the healthcare system.
The predictions outlined in the article aren't going to happen overnight and they won't be easy to pull off. They'll require investment of time and money and a serious shift in attitude about "The Way We Do Things."
The biggest barrier is attitude
There will be those who are skeptical about some of the predictions the sources in the story made. For example, I suspect many will scoff at the idea that, in the future, patients will take ownership of their own health—despite the growing number of wellness programs and the trend toward rewarding people for taking better care of themselves.
And plenty of physicians will say they just don't have time to e-mail patients—even though those who do say it's much more convenient than returning phone calls.
And I suspect there will always be doctors who think that they know best and who are insulted when a patient brings in computer printouts about alternative treatments for his or her condition or information about a new drug or the results of a new study—even though more and more consumers are turning to the Internet for health-related information.
And you know what? It's your prerogative to be skeptical. Hey, if you don't want to invest in an online appointment-booking program because you think it's too expensive or you worry that the program will somehow break down and schedule 100 patients in the same 20-minute slot, then continue to do things the same old way.
But if you want to stay competitive, want to grow (or at least hold onto) your market share, you ought to at least consider some of the scenarios outlined in the article.
What do you think? Are the predictions about the patient of the future on the mark or off the wall? Head on over to today's post on the MarketShare blog to share your thoughts—and make some predictions of your own.
Note: You can sign up to receiveHealthLeaders Media Marketing, a free weekly e-newsletter that will guide you through the complex and constantly-changing field of healthcare marketing.
I talked to LifeMasters Supported SelfCare, Inc.'s then-President and CEO Christobel Selecky less than a year ago about her company and how it forged ahead after a failed $307.5 million merger with disease management giant Healthways in 2006.
As one of the leading disease management/population health management companies, LifeMasters needed to do some soul-searching after its failed merger. It cut staff, and invested in technology and data integration. Selecky also told me her company was thriving in a dual-eligible CMS demonstration project in Florida by working with doctors and Medicare beneficiaries' families, and conducting face-to-face meetings with beneficiaries. In other words, using tactics not seen in traditional DM.
Now, just a year later, LifeMasters announced on Monday it has filed for Chapter 11 bankruptcy protection and Selecky has been replaced as president and CEO of the South San Francisco, CA-based company (Selecky, a population health management industry leader, is staying on the company's board of directors).
How did a company that a year ago seemed stable wind up filing for bankruptcy? LifeMasters is pointing at CMS. George Pillari, the new LifeMasters president, told me this week that LifeMasters owes CMS $125 million for participating in three demonstration projects over the past four years as well as "another few million" to other creditors.
The company, along with others involved in the Medicare Health Support project, which tested DM in the senior population, need to repay fees to CMS "earned in excess of savings generated during the multi-year projects" because CMS found the DM companies did not "demonstrate success based on CMS' study design and measurement methodologies," according to LifeMasters.
Pillari says the Chapter 11 process will give LifeMasters "resolution with CMS" and allow the company to move forward "just fine."
LifeMasters has to transition from a company that a year ago had one-third of its business coming from Medicare to moving forward without any Medicare business because their demonstration projects have ended.
Pillari adds the commercial business is progressing and LifeMasters cut staff associated with Medicare. "I think the rest of our business runs pretty well," he says.
While CMS says DM companies have not been successful in the Medicare population, the industry, in turn, questioned MHS' contract model and design and CMS' selection of Medicare beneficiaries who took part in the project (who critics charge were both too healthy and too sick to bring about cost savings).
But rather than question CMS and the MHS project, Ariel Linden, DrPH, president of Linden Consulting Group in Hillsboro, OR, says the industry should instead learn from the failed MHS project and LifeMasters' experiences. His conclusion: The classic nurse call center-based DM model is a failure and companies must change the design or face a disastrous future.
"Not only am I not surprised, I wonder how other firms haven't folded yet," says Linden of LifeMasters' bankruptcy filing.
Linden, one of the most outspoken critics of the traditional nurse call center-based DM model, co-authored an article with Julia Adler-Milstein of Harvard University that appeared in the Spring 2008 Health Care Financing Review in which he questioned whether commercial DM could achieve net cost savings in the chronically ill population.
The problem is, according to Linden, nurses calling from a call center once a month or less cannot have a real impact on reducing hospitalizations, improving health status, and cutting health costs. There simply isn't enough patient interaction in that design, he says.
Instead, chronically ill patients need remote monitoring and a medical home that seamlessly works together. He says large health plans already know this, see there is not a positive ROI in these programs, are bringing population health management programs in-house, and exploring the medical home model. While traditional DM vendor programs have lost favor, he says, other ideas like the medical home and tertiary care models are growing in popularity.
Not only is the model an issue, but health insurers have an advantage over disease management and population health management vendors because they already have patient data and can more easily build relationships with physicians. "[Vendors] have no relationship with doctors or the hospitals so there is absolutely nothing they can do except go through the patient," says Linden.
Linden says disease management companies need to realize that they should work to support physician practices and medical homes—and stop trying to go it alone with call centers.
"What they need to do is use their tremendous infrastructure to develop and support medical home-based models. Models that include a primary care physician or a provider that is a quarterback of the team, and build a team around that," says Linden.
"That's how they are going to have any chance to be viable in the long-term sense," he adds.
The House Democratic Steering and Policy Committee, which includes top leadership shepherding the tri-committee healthcare reform bill (HR 3200) through the House, received feedback on the bill from several provider groups and other healthcare experts during a healthcare reform forum Tuesday on Capitol Hill.
"We have a moral responsibility to pass health insurance reform, and we will do so this year," said House Speaker Nancy Pelosi (D-CA), who opened the forum. "It is a moral imperative: It is a health issue, [and] it is an economic issue."
While Pelosi mentioned her support of including a public insurance option in the healthcare bill, discussion focused on an array of other reform issues—from state insurance exchanges to comparative effectiveness—found in the 1,000-plus paged bill.
J. James Rohack, MD, president of the American Medical Association (AMA), said the AMA supported the insurance market reform provisions in HR 3200, which are related to "guaranteed issue, guaranteed renewability, modified community rating, pre existing condition limitations, nondiscrimination based on health status, adequacy of provider networks, and transparency."
He said the market reforms "should create a more competitive insurance market" in which plans eventually would compete on price and quality. This would allow patients "to gain more control over their choice of health insurance coverage and their own care," he added.
Tom Priselac, president and CEO of Cedars Sinai Health System, Los Angeles, and chairman of the board of trustees of the American Hospital Association (AHA), said the reform bill's proposal linking hospital readmission performance to Medicare payments was "overly aggressive."
As proposed, beginning in fiscal 2012, payments to hospitals, would be reduced for higher than expected 30 day readmission rates for heart attack, heart failure, and pneumonia. However, this payment cut would apply to all Medicare discharges—not just cases involved in a readmission, he said, which would create penalties that could be "significant."
The examination of hospital readmissions data "is relatively new and more work is needed to determine how to effectively reduce inappropriate readmissions," he said. The proposed policy would "financially punish hospitals without attempting to fix other shortcomings of the healthcare system."
He also said AHA "strongly believes" the legislation should include a pilot for accountable care organizations that allows groups of qualifying providers—including hospitals, hospital physician joint ventures, and hospitals employing physicians—to voluntarily form ACOs and share in the cost savings. However, AHA requested that leadership of an ACO should not be limited to physician groups and physician organizational models, as is currently stated in the House bill.
Mary A. Maryland, PhD, with the American Nurses Association Board of Directors, said her group supported many measures within HR 3200 "that would bolster the nursing profession"—particularly the focus on the Title VIII Nursing Workforce Development Programs. These would help "recruit new nurses into the profession," she said.
Former health insurance industry executive turned whistleblower Wendell Potter, in his testimony, told the panel that if Congress "fails to create a public insurance option to compete with private insurers, the bill it sends to the president might as well be called the Insurance Industry Profit Protection and Enhancement Act."
Potter also challenged one of the key arguments made against the public option—that it would have an unfair competitive advantage over private insurers. "Contrary to the misinformation being disseminated by the health insurance industry and its allies, the public insurance option would not have a competitive advantage over private plans," he said.
Bonnie Cramer, AARP's board chairman, said that "while AARP has not endorsed any comprehensive reform legislation to date," it would support those measures "that bring down healthcare costs" and those that end discrimination by insurance companies, strengthen and improve Medicare (such as by closing the Part D "donut hole," and guarantee "stable, affordable coverage."
She said AARP supported the House bill language that would provide subsidies to individuals up to 400% of the federal poverty level. She said it was "critically important" that Congress provide "adequate subsidies" to those who need extra help in purchasing insurance.
As the three major nurses' unions in the country came together earlier this month to form the largest registered nurses union in the U.S., some resistance remains from Massachusetts nurses' unions.
So far only one of the three unions has voted unanimously to endorse and join the proposed "super union." In a meeting held on September 10, delegates from the Oakland-based California Nurses Association (CNA) became the first organization to join the super union. The Oakland-based association represents 86,000 of the potential 150,000 nurses of National Nurse United (NNU).
After CNA's vote, this leaves the Massachusetts Nurses Association (MNA) and United American Nurses to vote on the "super union" proposal. However, some representatives of the Massachusetts union insist they want nothing to do with NNU.
"Our nurses are telling us they do not want this merger to go through," said Barbara Norton, a Region 5 regional director of the Massachusetts Nurses Association and chair of Brigham & Woman's Hospital's MNS bargaining unit in an official statement to the San Francisco Business Times.
"And that is the position we are going to take."
According to the California Nurse Association, the new super union aims to strengthen the ability of direct care nurses to protect and improve patient care conditions, improve nursing standards, win union representation in an "RN union" for all unrepresented RNs, pass state and national legislation to protect patients, and to work for guaranteed healthcare for all.
Before moving forward, the super union must gain approval of all three organizations without alienating major portions of each group's members.
The MNA will have an opportunity to express their opinions and vote on the proposed merger on October 1 in Brewster, MA.
