"If you include pharmaceuticals and healthcare manufacturing as part of healthcare, which we do in some of our numbers, you are talking about a sector that now produces 16 million jobs and will produce 20 million jobs by 2020, which is huge," Anthony P. Carnevale, the Center's director and the report's lead author, tells HealthLeaders Media. "By then it should be a 160 million job economy and 20 million of those jobs will be in healthcare, and there won't be any sectors bigger than that."
This might be good news for people on a certain career path, or for drug makers or medical device manufacturing companies. By 2020 one in five dollars created in the economy will go to healthcare. The healthcare sector already is the single largest source of new jobs in the overall economy, according to monthly job reports from the U.S. Bureau of Labor Statistics.
Is this growth in healthcare good for the rest of society? Carnevale says healthcare is among the least productive sectors of the economy.*
"There is a dilemma here and it gets at the root of the healthcare issue in general. We are paying twice what other advanced industrial nations for healthcare. They are at 9% of GDP and we are at 18% and headed for 20%," he says. "We've built a huge sector, but the productivity growth has been negative for a while. Our estimates on the productivity growth are basically -1%. In manufacturing productivity is +8%. We are supporting a huge apparatus in healthcare and no doubt there are huge inefficiencies."
Carnevale believes the healthcare sector cost and job growth are byproducts of an inefficient and fragmented healthcare system.
"One of the criticisms of healthcare is that it is a supply-driven system. The more doctors we have the more healthcare we consume," he says. "There is not much doubt that the American healthcare system is a Rube Goldberg device where there really is no natural means for price controls. We are only now beginning with the intervention of the federal government which is now up for grabs to try and make some sense of this."
"All the hospitals, each of the individual doctors, are individual entrepreneurs and they are all trying to maximize profits. And you have a third-party payer, which in many cases is the government, if I want something and somebody else pays for it, I tend to consume more of it," he says. "It is not a market. It needs to be rationalized to the extent that there is some relationship between consumption and cost; that there are prices attached to things and people make choices; where there is some discipline in the system that discourages waste."
"In most rational systems that means somebody has to be in control. The politics of healthcare are such that it is very difficult to arrive at that," he says. "To the extent that each of us wants to be an independent consumer and every provider wants to be an independent entrepreneur, you have a recipe for a runaway train in economic terms and that is what we have."
The study also found that:
82% of those new healthcare jobs—4.6 million—will require postsecondary education. As a result, Carnevale says, the demand for postsecondary education in healthcare will grow faster than in any other field except STEM (Science, Technology, Engineering, and Mathematics) and Education occupations.
Healthcare successfully competes for science and engineering talent. Healthcare, science, and technology fields require similar skills and healthcare programs at the associate and bachelor's level provide appealing alternatives for science and engineering students.
Healthcare reflects distinctly different work interests and values. People in healthcare jobs tend to value forming social bonds. People who gravitate to STEM occupations place a greater emphasis on achievement and independence.
Upskilling in nursing is growing especially fast. In 1980, 37% of entry-level registered nurses had at least an associate's degree; by 2008, that figure had increased to 80%.
Bachelor degree requirements in nursing is crowding out disadvantaged minorities. A total of 51% of white nurses 40 years old or younger have bachelor's degrees, compared to only 46% of Hispanics and 44% of African American nurses.
Healthcare has the largest number and proportion of foreign-born and foreign-trained workers in the U.S. Among healthcare workers 22% are foreign born, compared to 13% of all workers nationally. Most foreign-born nurses come from the Philippines, India and China.
Physicians are the highest income earners in the country and tend to come from mostly affluent backgrounds.
The growth in healthcare spending will continue in the near term, Carnevale says, regardless of how the U.S. Supreme Court rules this week on the Patient Protection and Affordable Care Act.
"Within states, there are going to be some administrative devices and computerizations of records that will create a system that is much more self-aware and with a lot more data," he says. "That is the direction in which we are going, although in the short haul over the next decade or so I don't think there is any reason to think the prices would stabilize."
(*Carnevale explains the methodology for measuring productivity: "We divide the output, the gross domestic product produced in healthcare by the number of people working. In healthcare the number of people are hiring faster than output is increasing. In the case of manufacturing, which is the highest productivity sector at the moment, you've got +8%, which means you are getting 8% more output with the same number of workers. In the case of healthcare, the workers are increasing but the output is going down slightly relative to the number of workers. The output per worker is going down, essentially.")
The average per capita cost of healthcare services covered by commercial insurance and Medicare programs increased by 6.14% over the 12-months ending April 2012, Standard & Poor's Healthcare Economic Indices show.
The uptick continues an acceleration of cost growth that began in October, 2011 and includes an almost half a percentage point jump from the +5.65% rate posted for the 12-month period ending in March 2012, the S&P Indices show.
David M. Blitzer, chairman of the Index Committee at S&P Indices, says the accelerated cost growth is linked to increased utilization but it's not clear what is driving the increased utilization.
Meanwhile, spending on healthcare is expected to continue on an upward trajectory, according to projections released Tuesday by the Office of the Actuary at the Centers for Medicare & Medicaid Services.
"It may be that we are far enough from the depths of the last recession that people are a little more upbeat about spending money," Blitzer tells HealthLeaders Media. "I know we are seeing that outside of healthcare. Consumer spending had a small recovery and consumers are willing to borrow. Compared with a couple years ago, people seem a little more relaxed about spending money, whether it is businesses or individuals. And I think that affects this as well."
Inflation in the overall economy, as measured by the gross domestic product, grew by 2.3% for the 12 month period ending in April, 2012, according to the U.S Bureau of Labor Statistics.
Healthcare costs covered by commercial insurance plans increased by 8.46% over the year ending April 2012, up from the +7.78% reported for March 2012, and Medicare claim costs rose by 2.6%, up from March's +2.42%. Professionals annual growth rate also increased from its March 2012 +5.58% rate to April's +6.18%, and the Hospital Index annual growth rate increased to +5.81% in April, from its +5.44% March rate, S&P reports.
Blitzer says healthcare cost growth is nearing the top of the indices ranges that have been established over the last several years and he's not sure when it will abate. "It came down in 2007 due in part to the economy softening, but as you get farther away from the rate of inflation rate, people get antsy," he says.
He added that it's "nearly impossible to tell" if the Patient Protection and Affordable Care Act has affected cost growth in any direction. "The few things like expanding the population of insured people between 19-26 years old have already been baked into this for a couple of years. It's not clear whether people have started implementing stuff that might get turned down by the Supreme Court," he says.
The S&P Healthcare Economic Indices estimate the per capita change in revenues accrued each month by hospital and professional services facilities for services provided to patients covered under traditional Medicare and commercial health insurance programs. The annual growth rates are determined by calculating a percent change of the 12-month moving averages of the monthly index levels versus the same month of the prior year.
Healthcare costs began to accelerate in May 2009 and peaked in May 2010, before decelerating through the first half of 2011. The current acceleration trend began in October, 2011.
A further breakdown of S&P indices shows that: the Professional Services Medicare Index rose 3.11% in April, up from March's +3.01%; the Hospital Medicare annual growth rate rose 2.04% in April from its March +1.80% rate; the Professional Services Commercial Index increased to 7.74% in April, from +6.86% in March; and the Hospital Commercial Index rose 8.85% in April from the +8.39% posted for March.
If cost growth continues at this pace, Blitzer says, businesses that provide health insurance to their employees could be "moaning and groaning" this fall when they renegotiate with health plans.
Any comparisons of urban and rural healthcare costs come freighted with caveats.
For starters, rural hospitals usually cannot provide the array of specialized and expensive care seen in larger urban hospitals, making per-patient cost comparisons difficult. There can also be stark differences in patient populations. And rural hospitals do not enjoy the economy of scale and leverage with vendors and insurance companies that are seen in larger urban hospitals. Critical access hospitals get higher reimbursements from the federal government for care delivery, further muddying comparisons.
Still, there is a nagging perception out there that the 1,700 or so management teams at rural hospitals across the nation don't provide the same level of care delivery value as urban hospitals.
A study by Portland, ME-based consultants iVantage Health Analytics challenges that perception.
"We just keep seeing the data repeat the fact that on the measures the industry is looking at--safety, process, outcomes, satisfaction, the big value measures--we don't see gigantic differentiation between urbans and rurals," says iVantage Executive Vice President John R. Morrow.
Lower costs for rural care
The study says cost per Medicare beneficiary is 3.7% lower overall for rural vs. urban beneficiaries, which would represent about $7.2 billion in annual savings if the average cost per urban beneficiary were equal to the average cost per rural beneficiary. Medicare already benefits from $2.2 billion of lower beneficiary costs for care delivered to rural beneficiaries vs. urban.
"When we look at Medicare costs per beneficiary for inpatient outpatient and physician care the cost per beneficiary we see rural costs are 2.7% lower than urban costs," Morrow says. "That doesn't include just the costs incurred in the rural setting. That is cost assigned to the beneficiary. So when the patient goes to Boston for a hip replacement those costs are assigned to his home, not where he had the care."
Access to physicians
In addition, the study found that in rural hospitals physician services payments are 18% lower, and hospital service payments are 2% lower, but outpatient service payments are 14% higher for Medicare beneficiaries. Morrow says that may be due largely to the use of the emergency department for non-emergency care.
"The big issue in rural care that people are stuck on is the access issue," Morrow says. "People talk about there not being any primary care and some of the evidence in our study points to the fact that people go to the rural emergency department during normal daylight business hours at a much higher rate than at all hospitals. We also see the severity level of patients in the rural EDs being lower than that of patients attending any emergency department. That supports the idea that in rural America people use the ED for primary care."
Efficient ED care
Morrow agrees that the ED is an expensive option for non-emergency care. But he says his study found that rural ED patients see a physician 30% faster and spend about 33% less total time in the ED than urban ED patients. In addition, rural ED visits result in less than half the hospital admissions than in other national benchmark reports of all hospitals.
"We are able to document that people get seen quickly," he says. "It may cost more, but they get to see a physician faster than if they were in an urban setting and they spend less time in the ED. Maybe the rural ED has figured out how to solve for the lack of primary care access. That may not be a bad thing. It's just different from what everyone else is saying."
Morrow says that the case against ED utilization may be relying too much on data collected at urban hospitals and projected onto every hospital regardless of its size, status, or mission.
"The data we see from large urban areas if you apply it nationally would be a bad thing," he says. "So there is an effort to keep people out of the ED. OK, that may be true but in rural settings it is not such a negative. What is the alternative? Loading up rural America with primary care physicians?"
Morrow says ACO designers would be well served to re-examine the role that rural hospitals play in managing patient population health.
"They have had to do it because they have a more non-transient population base," he says. "If you are an ACO or a mother ship hospital in a suburban setting there is something to be learned from the rural hospital that is your feeder hospital. This generalization that rural hospitals are crap it doesn't play out in the data. They are doing what they do pretty well.
The Bureau of Labor Statistics reports that the nation's hospitals employ more than 4.8 million people, making these centers of healing powerful economic engines for the communities they serve.
Unfortunately, when it comes to diversity in the workforce, hospitals are not leading the way. According to a survey from the American Hospital Association's Health Research and Educational Trust, minorities represent 29% of all patients, but only 14% of hospital board members, and 14% of executive leadership.
"We have a long way to go and we knew that," says Matt Fenwick, director of Program and Partnership Development at HRET. "This survey was our attempt to understand where we are in the field so we have hard figures so that going forward we can set some goals and milestones. The survey does crystallize this issue for a lot of folks."
Still, some progress is being made. HRET says 65% of hospitals incorporate diversity management into their budgets, 48% have action plans to recruit and retain a diverse workforce that reflects their patient population, and 42% have a program to identify qualified minority workers for promotion.
The push for workforce diversity is not about being politically correct. Ultimately, if a hospital's workforce more closely resembles the patient population it serves quality measures and patient satisfaction scores will improve.
"You need a diverse staff," Fenwick says. "That's not to say you can't achieve incredible things with a staff that is not as reflective of the community as it could be. But with a diverse staff you have this intuitive understanding of those you are treating."
Indiana University Health and flagship University Hospital – Indianapolis has received national recognition for its efforts to improve diversity among its 30,000 employees. Steven L. Jones, the health system's executive director for Talent Management and Diversity, says the patient population is about 30% minority and the workforce is about 23% minority.
"When you think about the hospital experience it can be overwhelming, so it is our contention that we need to make that patient experience as comfortable as possible," Jones says. "We want to provide patient-centered care and part of that is providing that patient with an environment where they see people who look like them. I believe just like we tend to gravitate toward people who look and talk like us, the same thing occurs for patients in their families when they come to the hospital."
In this era when skilled clinicians are hard to find, most hospitals can't realistically be expected to have a workforce that mirrors their changing patient populations. If that is the case, Jones says it's important to train existing staff for the cultural differences they may encounter.
"You can provide quality patient care without having, for example, a Burmese patient treated by a Burmese nurse or physician," Jones says. "But organizationally you have to make sure that employees are aware of these differences and they are sensitive enough to know that differences aren't necessarily a bad thing. Employees must understand those differences need to be addressed on the front end so we can provide that care where a patient feels comfortable enough to raise concerns without it being a situation that leads to poor patient satisfaction and poor quality of care."
At IU Health, Jones says the initial push for workforce diversity was met with skepticism.
"Some people believe that when we became intentional about increasing the numbers of minority professionals that this was about just hiring someone because they happened to be Korean- or African-American and they happened to be a pharmacist on top of that," Jones says. "That was never the intent. It was always about finding the best talent available. We had to help people understand that the focus from an HR perspective was on qualifications and not just skin color."
If hospitals and healthcare organizations aren't making a move toward a more diverse workforce, they will find themselves falling further behind the nation's rapidly changing demographics.
"Most researchers will tell you by 2020-2030 minorities will become the majorities in the U.S.," Jones says. "The discussion needs to be about how do organizations get to the point of being able to fully embrace diversity in the workplace and how we are then culturally competent and sensitive to the patients we serve."
Ridiculing coworkers, clumsy and callous patient transfers, texting during meetings, and leaving work early were among a handful of rare, but unprofessional behaviors attributed by some hospitalists to themselves and more so to their peers, a survey published in the in the Journal of Hospital Medicine shows.
The survey and study asked 77 Illinois hospitalists to identify what they considered unprofessional behavior in themselves and their colleagues.
Funded by the Society of Hospital Medicine, the study found that the most common unprofessional behaviors that hospitalists reported participating in were:
Having personal conversations in patient corridors (67%),
Ordering a routine test as urgent to expedite care (62%),
Signing out a patient over the phone when it could have been done in person (41%)
Making fun of other physicians to colleagues (40%).
Not surprisingly, when hospitalists were asked if they observed those behaviors in colleagues, the figures were much higher, at 80%, 80.5%, 66%, and 67.5% respectively.
Study coauthor Vineet M. Arora, MD, from the Department of Medicine at the University of Chicago, says there is growing concern about the discrepancy between what is taught about professionalism in formal medical education and what is seen on the ward. She says government regulatory agencies are also pressing medical schools to evaluate their learning environments and the impact on professionalism.
"We had been doing some work about professionalism among students and residents. There is a lot of literature in those areas that the learning environment in academic medical centers may not be as positive at all times as it should be. We often heard from student residents that we should expand our work to include faculty to better understand role models in the learning environments," Arora told HealthLeaders Media.
"We were reassured that the numbers for alarming behaviors were low. We had surveyed the same behaviors in medical students and residents previously. This is completing the arc to understand what role faculty play."
Arora says the survey's findings were used to build an intervention program video for behaviorally challenged hospitalists.
"We are not stating what is unprofessional. We want to know what the hospitalists think is unprofessional," Arora says. "We used a range of behaviors from extremely egregious to not really an issue. Talking in the hallway is not the same as disparaging the patient or backdating a note. We wanted in the survey to provide heterogeneity of behaviors so people could decide what was grey and what was definitely black and white."
"The idea wasn't 'let's go find out what the bad things are in the workplace.' We wanted to develop some targeted educational interventions to improve the learning environment but before we did we wanted to know the behaviors to target," she says.
Nearly 80% of the hospitalists who took part in the study completed their residency after 2000, 57% were male and 61% had worked with their current hospital group for one to four years. They graded more than 30 unprofessional behaviors on a five-point scale commonly used to measure attitudes or opinions.
Arora noted an interesting correlation between job characteristics of hospitalists and reports of unprofessional behavior.
"Hospital-based physicians have very different types of jobs based on whether they teach, or do administrative work, or clinical or night work and we found that your job type predicted some of the behaviors you participated in," she says.
"People often say the more clinical work you do the more burned out you will be. It turns out that actually in our studies the people that had less clinical time were more likely to engage in behaviors of making fun of people. We found an inverse relationship."
Arora says the findings suggest that clinicians put a premium on maintaining good personal relationships with colleagues.
"Contrary to popular belief those physicians who are doing more clinical time actually were less likely to report unprofessional behavior in certain domains," she says. "Whereas if you don't do a lot of clinical work and your primary job is research or administration, maybe you are more likely to fall into the environment of making fun of people in the workplace."
The nation's safety net hospitals are concerned that the proposed cuts to disproportionate share payments that take place next year under the Patient Protection and Affordable Care Act may not be on the same timetable as the expansion of health insurance coverage.
Beth Feldpush, vice president for advocacy and policy at the National Association of Public Hospitals, says that specific cuts to DSH payments were written into the ACA regardless of whether or not healthcare coverage is extended to an additional 50 million people who are currently uninsured.
"We remain very concerned about the size of the DSH cuts," Feldpush told HealthLeaders Media. "With a little bit of hindsight at the ACA and looking at where we are with implementation, we are concerned we are not going to see coverage expand as quickly as we would optimally hope it would. I haven't seen anyone really do an estimate of how quickly we would get to that full coverage expansion."
DSH payment cuts totaling more than $22 billion for Medicare and $18.1 billion for Medicaid over 10 years are supposed to take effect beginning in federal fiscal year 2014, Feldpush says.
The fate of the PPACA remains in the hands of the U.S. Supreme Court, which is expected to rule this month on the constitutionality of the sweeping healthcare reforms. With so much uncertainty surrounding the law, Feldpush says there has been some reluctance to implementing key provisions that could help safety net hospitals.
"We know for certain that at least on the health exchange side the implementation in states is going a little slower," Feldpush says. "Obviously they have been bogged down by the constitutional challenges to the law. There are a lot of states that have not moved quickly either because they are opposed to the exchanges or they are not sure it is going to remain in the law. That is all happening slower than people had anticipated."
NAPH this month released a study showing that the nation's safety net hospitals represent 2% of all acute care hospitals, but delivered 20% of all uncompensated care in 2010. NAPH said its annual member characteristics report, America's Safety Net Hospitals and Health Systems, 2010, found that its member hospitals delivered increasing levels of outpatient and inpatient services and uninsured patients accounted for 30% of ambulatory care visits and 19% of inpatient services.
The 52-page report said that the average margin for NAPH hospitals was 2.3% in 2010, compared with 7.2% for all hospitals. Safety net hospitals would have suffered a 6.1% loss without Medicaid DSH payments and a 10.6% loss without DSH and other supplemental Medicaid payments, the report said.
Under a preferred scenario, Feldpush says DSH payments would gradually decline each year as coverage expands. "Unfortunately when the ACA was being written, the Congressional Budget Office could not give a savings score to that implicit understanding of a natural decline in the need for DSH," Feldpush says.
"That is how we ended up with those direct cuts that are tied into the law. We would have said we don't need to put any DSH reductions into law at all because we will be gradually spending less on this program as coverage expands."
The PPACA provides a framework but gives broad implementation powers to the Health and Human Services Secretary Kathleen Sebelius and the Centers for Medicare and Medicaid Services. Feldpush says NAPH is also asking them for a review of how DHS payments are distributed.
"In addition to cutting the shared total dollars there is going to be a redistribution of the DSH dollars," Feldpush says. "Our advocacy efforts are focused now on the implementation approach to make sure remaining DSH dollars are distributed to hospitals with the highest needs—that is those hospitals that really do take care of the disproportionate burden of the low-income patients."
The report also found that safety net hospitals:
Averaged almost three times the volume of inpatient admissions seen in other acute care hospitals and exceeded average admissions within their markets by 44%.
Provided nearly $128 billion in inpatient and outpatient services, nearly half of which was for low-income patients.
Trained more than 19,000 full-time equivalent medical and dental residents and more than 300 FTE allied health professionals.
Reported uncompensated care averaging 16% of costs, compared with 6% of costs for hospitals nationally.
Represented 37% of the level 1 trauma care and 57% of the burn care beds in the 10 largest U.S. cities. In 31 communities nationwide, safety net hospitals are either the only level 1 trauma center or the only trauma center of any level.
For much of his life, John Arnold, 64, of San Francisco, earned a good living in corporate America with a resume that includes senior executive status at Seagate, Novartis, and most recently, Pepsi Chicago.
He retired a few years ago, but quickly learned that he wasn't quite ready for a life devoted to leisure. While not aching to get back into the corporate grind, Arnold was looking for something that would fulfill a greater sense of service to his community.
"I decided that my skills were still applicable and my experience would be beneficial and I wanted to identify an area where I might be able to provide some meaningful benefit and at the same time have that recognized in a structured way," he says.
"I had tried volunteering and my experience has been that that was not satisfactory, that you could wind up stuffing envelopes and things of that sort and that is not what I had in mind to try to use my time if I was going to be involved."
Arnold, an MBA, says his professional expertise includes an extensive background in corporate senior level finance and significant hands-on experience with process development and program management work.
A career in corporate America has also honed his diplomatic skills. "I have an appreciation of the implications of trying to make change in a large and complex environment," he says. "That is difficult. It has to be approached with humility. I have learned through first-hand experience that when you are changing anything having to do with someone's job you have to be very aware of the fact that for most of us there is probably nothing more important than what we do. So when you are making these changes you have to engage these people and bring them along."
Arnold turned to The Encore Fellowship Network, a program that originated in 2009 to tap into the expertise of Silicon Valley executives. The program has expanded across California, with similar programs now in Arizona and New York, all of which share the mission of identifying executives and other innovators who are willing to share their expertise to tackle stubborn social issues.
In The Encore Fellows program, participants work anywhere from six months to a year with stipends generally ranging between $20,000 and $35,000. Half of the stipend is paid by the California HealthCare Foundation and the remainder paid by the organizations that receive the expert help.
After an interview and screening process, Arnold was taken on as an operational analyst and consultant in July 2011 for La Clinica Del Raza, an Oakland, CA-base community health system with 29 clinics in three counties.
"I am working in support of the CFO. One project is designing a process to improve their cash handling," Arnold says. "They have a lot of facilities and they take in a lot of cash. Generally speaking, in the finance and accounting arena, cash handling is a big deal. There are major compliance concerns."
Arnold has a one-year contract that requires him to spend a minimum of 20 hours each week working for La Clinica, for which he is paid $25,000. The contract expires at the end of July, but Arnold hopes to re-sign with La Clinica because he wants to be there when his cash handling strategies are implemented.
"I am in the process now of rolling out a design that I created, training down to the clerical level at their various large sites, and hoping I can get all of this done before my contract expires," he says.
Arnold says he hopes to be there for another year or two for the implementation, to troubleshoot the process, and to provide post-implementation assessment. "You become invested when you design something and you feel strongly that it is going to be a significant legacy benefit that is going to be sustained beyond your actual involvement," he says.
While he doesn't need the salary Arnold says the pay sends an important message.
"As a society and in any major enterprise we tend to have a greater respect for that which we are paying for," he says. "Based on my prior attempts to volunteer I found that absent their being some skin in the game there wasn't the corresponding commitment on the part of whatever organization you might be involved with."
That commitment takes the form of simple things like adequate work space, a telephone, a computer, and access to stakeholders and resources. "Without that, then you are basically put into an environment where you have to, more or less on your own, address those kinds of concerns," he says.
While receiving a stipend is important symbolically, Arnold says he is motivated by a sense of satisfaction.
"The opportunity to take my prior experience and to continue to learn and have the satisfaction knowing that what I am doing is making a difference is a tremendous satisfaction to me. In this country we need to think differently in terms of what retirement consists of and how you approach that from an expectation standpoint," he says.
"There is the opportunity to learn in a new area and learning is key to life. If you aren't learning you are dying."
This article appears in the June 2012 issue of HealthLeaders magazine.
In our annual Industry Survey, leaders cite patient experience and satisfaction as their organization's top priority, and 59% place it among their top three priorities. And yet when assessing how their organization is doing in that regard, only 18% choose "very strong." While 47% describe their organization's patient experience as "strong," 35% classify it as "neutral," "weak," or "very weak." What is behind the industry's inability to do better in an area that leaders regard as a top priority, and what can be done to improve?
Eleanor Keller
Director of Inpatient Service
OSS Orthopaedic Hospital
York, PA.
A lot of what we do is make sure our staff is taking excellent care of our patients—making sure their pain is under control, making sure their needs are met on their time—because the time that a need is met to me may be different from anybody else.
A lot of people have become complacent and don't seem to put the priority on patient satisfaction. We have a lot of competition and many of our patients come to us because of word of mouth from other patients who were satisfied, and we don't want to lose that. A lot of organizations don't see that. They might think, "I'm good and everyone is going to want to come to me."
We've only been open about a year and a half. So it was not so much changing the behavior, but as people came on board we had them recognize that this is what we want to be and this is what we have to do to get there—and we had to make sure they were on board with that.
In established hospitals, it's always harder to change behaviors to what you want, but when you interview, you interview for the behavior.
Edwina Henry
Director of Quality and Risk Management
ENNIS (Texas) Regional Medical Center
We are too passive. We throw those patient experience questions out there and we only react to the results we get. We aren't sitting down face-to-face with these folks and asking them to tell us what it means from their perspective.
From my experience, one aspect we worked ad nauseum was "the food is lousy." As it turns out, the patients weren't happy with the food because it was bland or "you only send me this or that," and they had no understanding of what diet they were supposed to be on. There was no communication with nursing on the plan of care and understanding that there is a no-fat diet or a no-salt diet or a bland diet for problems with ulcers.
We use a lot more task-based practices than critical-thinking and team skills. Although we see it, we don't exactly know how to fix it so we don't communicate well. Everyone is in there to do their task and says, "I don't want to be involved in anything else." That crosses over to the patient: "Well, I'm just supposed to give you this pill. I'm not supposed to really worry about whether you know what it is." So there is a disconnect there.
We need to engage families to help us understand what makes patients happy, to get some idea of where the gap is and how to close it.
Deborah Visconi
Director of Operations
Morristown (N.J.) Medical Center
In order to improve the patient experience, it is critical to make satisfaction a top priority and area of focus for the organization. A key factor in being successful is the involvement of the entire healthcare team. So you have to include your physicians, nurses, ancillary staff, support departments, because everyone is critical to achieving the same goal.
It goes back to focus, priorities, and accountability. Most of our challenges are in the domain of communication. To achieve success in improving patient satisfaction, you have to establish accountability and focus the organization to put satisfaction as a top priority. In leadership we say, "Oh, yes, this is really important." But when we get distracted with other initiatives it can be easy to lose sight of the bigger picture of improving the patient experience.
If you do hourly rounding and you do it right, you diminish the patients having to press the call bell to meet their needs. If you are rounding on the patient every hour, you should be able to address those needs before they ask you. Hourly rounding is a key tactic that is critical in improving the patient experience by allowing the healthcare team to anticipate and meet the patients' needs before they have to ring the call bell. It helps us to understand what responsiveness means to each individual patient and their caregivers.
We've started putting the behavioral expectations in very specific detail into the performance appraisal for all employees, and patient satisfaction is part of your performance expectation.
Susan Stone
CNO, Sharp Memorial Hospital
San Diego
On overcoming obstacles: When you ask people "Are you patient-centered?" they say "Of course." But the definition of what it means is truly different for each hospital, and that has been a barrier in the healthcare industry. An extraordinary experience for the patient comes from the attitudes and behaviors that are exemplified by the personnel. And if you refocus your workforce on the priority of the relationship, they will have much greater success.
On listening: It is very important that the voice of the patient is involved in every aspect of the facility. We meet monthly with our patients and get their opinions on the work that we are doing. In addition there are some best-practice models of patient- and family-centered care that have demonstrated significant differences in outcomes related to the HCAHPS survey.
On the business case: When you get down to it, when you are talking about people who look at the bottom line and ask about the return on investment, it hasn't been clear to them about what that difference can be. In the study we did regarding patient-centered care models over five years, the patient satisfaction was significantly higher, the cost was actually lower in the facility that had implemented that model of care, and the return on investment was a lower length of stay. That is a success story. Those are the kind of success stories our industry needs but few have been in the literature for healthcare executives.
This article appears in the June 2012 issue of HealthLeaders magazine.
While there is not a definitive link showing that healthcare workers are more susceptible to overweight and obesity than other workers, some studies suggest that is the case.
Empirically it resonates because long hours, irregular work schedules, and on-the-job stress, which are virtually written into the job descriptions of many healthcare workers, have been identified as drivers of overweight and obesity.
Those stresses and their cumulative effect on employee productivity and healthcare costs is another reason why the wellness movement has grown tremendously in the healthcare sector.
When employees are screened for wellness measures such as blood sugar, body mass index, and hypertension, experts say employers should also include confidential questions about binge eating, which may be more prevalent than previously thought, evidence suggests.
A study from a Johnson & Johnson affiliate Wellness & Prevention, Inc., reviewed health risk assessment responses from 46,818 employees and estimates that a company with 1,000 employees loses nearly $108,000 each year because of productivity losses associated with binge eating. Researchers at W&P said 9.4% of the employees in the survey self-reported as binge eaters, making it the third-highest health risk affecting productivity behind depression and stress.
In other words, 94 employees in a 1,000-employee workforce that is earning the national average salary of $44,000 are each costing their employers more than $1,100 each year in lost productivity in the form of added healthcare costs, lost work days, and subpar productivity while at work; aka "presenteeism."
Richard Bedrosian, W&P's director of Behavioral Health and Solution Development, says binge eating can afflict anyone, but is three times more common among obese employees (17.8%) than among non-obese employees (5.5%). A separate study from W&P showed that the incidence of binge eating rose in proportion to employees' BMI. "If you look at Class 3 obesity, almost 28% of those people were binge eaters, but not everyone who is obese is a binge eater. Moreover, there are people at normal weight who are binge eaters," he says.
Binge eating is a disorder that closely resembles an addiction, but Bedrosian says, it is complicated. "That is not settled, whether that is literally an addiction the way someone is addicted to a drug," he says. "But the behavior resembles what [addicted] people would do. Let's take a non-physical addiction, someone with a gambling problem. That would be similar because people use any kind of compulsive behavior to manage negative emotions."
"The biggest difference in terms of the recovery is if you have an alcohol problem the solution is you simply stop drinking," he says. "The person who is trying to recover from binge eating has to develop a better relationship with food, because obviously they cannot stop eating."
Binge eating can be easier to conceal from family, friends, and coworkers because it is often done alone, and in private. "It is eating when uncomfortably full, eating when not hungry, eating when emotional. It is that feeling of loss of control that separates it from just average overeating," Bedrosian says. "A good example for binge eating could be something that somebody does late at night after supper. They are alone in their apartment, they open the refrigerator and there is a quart of ice cream. They finish it and look in the cupboard and there is half a box of cookies and they finish the cookies."
While he hasn't seen any data to indicate that binge eating is prevalent in healthcare occupations Bedrosian says in "any population where there are more obese people there are probably more binge eaters."
Bedrosian identifies "two pathways" into binge eating.
"One of them is people eating to manage negative emotions or stress. When any group of people is under more stress then you are probably going to see an increase in all of the kinds of behaviors that people use to manage it," he says.
The other pathway is yo-yo dieting. "For some people, going on restrictive diets, or going long periods of time without eating or restricting calories actually triggers a binge," he says.
Identifying eating disorders is critical to any weight management program.
"If you are binge eating it is going to be very hard if not impossible to manage weight without getting that behavior under control," Bedrosian says. "Any kind of gastroenterological surgeries that are performed, most of those programs require people to get screened for eating disorders. If they detect that they treat it before the do any surgery."
Bedrosian says the best way to identify binge eating is to ask employees in confidential health assessments. "I don't think an employer especially should be directly questioning people," he says. "If there is a health risk appraisal people can take this and be secure that the information is confidential and will not go to their employer or anyone else they don't want to reveal it to. That is the best way to get people to open up."
"It could be in a computer-based survey where person gets one-on-one feedback that they don't necessarily share or a clinical interview with healthcare provider," he says. "What I'm suggesting is you give people different ways of sharing that information. If someone doesn't necessarily want to come forward then educating about binge eating can be part of the curriculum in a weight management program."
This article appears in the May 2012 issue of HealthLeaders magazine.
In our annual Industry Survey, healthcare leaders place cost control and process improvement as their third-highest priority for the next three years (behind patient experience and satisfaction, and clinical quality and safety). They also cite labor, government laws and mandates, and information technology as their top healthcare cost drivers. How difficult will it be to be to achieve significant, sustainable spending cuts, and which line items present the best opportunities?
Tammie Brailsford
COO, MemorialCare Health System,
Fountain Valley, Calif.
The degree of difficulty will depend upon how far along healthcare organizations are in this endeavor already. For those that are beginning today and trying to achieve the 20%–25% reduction in overall expenses in order to thrive on Medicare margins, it will be very difficult. For those that have a culture of financial discipline and rigorous cost control in place already, it is doable.
MemorialCare is very far along in this journey. We started in 2009 immediately after the financial crisis of 2008. We established a goal of reducing our expenses to be able to thrive at Medicare margins. We have had a plan that we have been chipping away at ever since then.
Where are the greatest opportunities? We believe they are in rigorous labor and productivity management. It's using Lean to identify waste and to eliminate it. It is utilization management and partnering with physicians to ensure that the right things are done for patients—not more, not less. And it is care model redesign—looking at the levels of care, where patients are receiving the care, and making sure they are getting the proper care at the right level.
Jack Kolosky
Executive Vice President and COO,
H. Lee Moffitt Cancer Center & Research Institute,
Tampa, Fla.
If we look at it as just cost reduction, then I would put the other two— patient experience and clinical quality and safety—as the two higher priorities. At Moffitt we think that process improvement, what we are calling clinical transformation, really can lead us to all of these things: cost reductions, improved safety, and improved patient experience.
We think that there are various points in the system that are not value added. Indentifying those points is probably the easy part—where there are additional steps in the processes whether because of paperwork, or people double-checking something, or a lack of automation. Those are also frustrations for the patients, particularly for our cancer patients. One of their most precious commodities is time. They don't have time.
We can't cut costs and reduce the amount of patient safety. We know we have to increase it. We know that the process is one of the biggest problems in patient safety. So how do we improve the process and reduce those opportunities for errors on a going-forward basis? It's the same thing with the patient experience.
Mina Ubbing
President and CEO,
Fairfield Medical Center,
Lancaster, Ohio
When you look at patient experience, satisfaction, quality, safety, cost control, and process improvement, they are not mutually exclusive from one another. We have a time right now to be creative. We can make cost controls stick if we get to the right size and realize that, given all the regulations we have—particularly for community hospitals—a hospital like mine can't be all things to all people.
What is the definition of a community hospital anymore? If we can get those pieces of the puzzle well thought through and if we can get some experience and traction about what is going to be, because we are still making rules on the fly, there are some very good things there.
We are going to look at processes. What is not value added to the things we do? And that comes back to the voice of the customer, which comes back to patient satisfaction. Quality and safety and doing it right the first time certainly cuts costs out of your system because you don't have to do it a second time. Mitigate some risk. Some of these things are going to work hand in hand.
Dean Swindle
CFO, executive vice president for business services,
Catholic Health Initiatives,
Englewood, Colo.
On the challenge ahead: To get effective sustainable transformational cost movement, you are going to have to engage your clinical folks and have a partnership that redefines how you deliver care and make it a process improvement. At the same time you are trying to maintain what level you have of patient experience, and take that into consideration as you re-define processes. It will be the most difficult thing that any of us have done in this industry.
On cutting versus changing: You try not to use the term cost cutting because it alienates three fourths of the workforce. But at the same time it doesn't give credit for what needs to be done because you do need to change processes. Even broader, you are going to see some saying we need to change how the operating model is set up.
On surviving the transition: Everyone knows we have already done a lot, but it's not enough and the traditional way of looking at it is not going to be enough. Having transformational change in how we do our work every day across the board is a daunting task. A lot of us are still trying to survive in the current environment of fee-for-service as we migrate to who knows where we are going even as we are being held accountable for value and quality.
On the need for efficiency: Cost efficiency and effectiveness now becomes much more of an integrated part of a broader theme. We have to keep finding efficiencies. Because of the uncertainty of volumes and revenue that we have experienced in the past couple of years, and which will continue, cost will become more of a discussion point because it is something people feel you can control more than the uncertainty around revenue.
This article appears in the May 2012 issue of HealthLeaders magazine.
