It's always nice to have a trip to San Diego in the middle of heat wave. Got on the plane in Nashville Sunday at 10:00 a.m. at 92 degrees and climbing, with high humidity—and deplaned in San Diego three hours later at 70 degrees and very little humidity. But you're not reading this for a weather report.

I'm here because the American Hospital Association's Leadership Summit is being held here, and for some reason, they kick the thing off bright and early on Sunday.

I got here too late to attend the early sessions, but in time to catch the first keynote speaker, Tom Brokaw, who needs no introduction.

As a septuagenarian, he pretty much gets to do what interests him these days, and what interests him is the divisiveness that paralyzes our public discourse, our politics, and even our interpersonal relationships—at least that was my take on his talk.

I was curious about what one of the biggest news personalities of all time would have to say about healthcare, and I wasn't disappointed—he has eight physicians in his family. More on that soon. But as you might imagine, Brokaw started by tackling a bigger subject than healthcare.

"What happened to the America I thought I knew?" he asked, rhetorically.

For a man who lived through and covered 1968, with its race riots, Vietnam, and the assassinations of Robert Kennedy and Martin Luther King Jr., that's a pretty damning question all by itself. "Have we become so divided that we are headed for a crash landing?"

He used a medical analogy to describe the problems we're facing as a nation.

He likened the country to a patient who has arrived at the emergency room after undergoing a massive trauma. Experts, including various medical specialties are all there, and as the patient is suffering in the ER, they refuse to talk to each other because each of them is so egotistical that each thinks they know best how to treat the patient's problems and that their solution is the only one that works. Meanwhile, the family is aghast as the patient suffers and his condition weakens.

The problem: we're the family, and the politicians are the doctors who refuse even to communicate with each other—much less find a compromise solution that will get the patient back on his feet again.

"We have become more divided than united," he said.

We owe more than that to the men and women who serve in today's military, he says. We are now fighting two of the longest wars in American history, and only about 1% of the population has had to make any sacrifices. When they get back, he says, they must ask themselves, is this what we're defending?

We owe more to them, our children, and to the future of this country than to wallow in our differences, he says.

Brokaw reaffirmed his belief in American exceptionalism—the belief that we are the world's beacon of opportunity, but that notion is in jeopardy.

He told a story of three exceptional public servants, senators Bob Dole, Phil Hart, and Daniel Inouye, all of whom recovered together after receiving grievous wounds in the Second World War. They resolved together to dedicate their lives to public service, after growing up in the Depression only to be sent off to fight two of the biggest military powers the world has ever seen in Nazi Germany and Imperial Japan.

Despite political differences, the three senators managed to work together, as did dozens of others in postwar America. Now that spirit of cooperation has been lost.

Brokaw told of a conversation he recently had with two young congressional staffers, friends who worked for a Democrat and Republican representative respectively. The two friends get together to eat, drink, and talk politics frequently, finding that they agree more than they disagree. Meanwhile, their bosses, the purported leaders of this country, refuse to be in the same room with each other.

Brokaw encouraged healthcare leaders to avoid the same trap. He encouraged various healthcare stakeholders to work together with rivals to increase value and transparency.

"How can you work together to help people?" he asked. "It's not about tech bells and whistles and ordering tests."

That will prove a shining example to the rest of us, he says, who need to "re-enlist as citizens."

On Monday, I expect to be able to report on some of the success stories of those efforts as we get further into the conference.

Efficiency is often in the eye of the beholder. I was just talking to one of my colleagues the other day about working hard versus working smart, and I was making the case to him that I feel like I work as smart as I possibly can. Without that sense of efficiency and juggling as many projects as I can at once, none of them would ever get done. But that doesn't mean I'm necessarily right. If someone who knows what they're doing got into the science of how I work, I'd be willing to be they could find at least a few ways I could improve my work capacity.

Margaret Van Bree had a similar thought nearly two years ago as she took the reins as CEO of St. Luke's Episcopal Hospital, the flagship of the health system of the same name in Houston.  

"We benchmark our performance against other hospitals, and we have a higher case mix index than many in the country," says Van Bree, who holds a doctorate in public health from Tulane. "But still, our length-of-stay was longer than it should be."

Not only that, but Van Bree is a firm believer that efficiency and quality in healthcare are directly related. Walking the halls, she says, the hospital seemed to be operating at capacity, only it wasn't.

"People were operating at this feverish pace," she says. "It wasn't like we were running at 95% occupancy and it had to feel like a fire drill. Yet people still had to use heroic efforts every day to keep up."

Decision-makers at St. Luke's were interested long term in building a replacement facility, but first, they wanted to make sure their current facilities were being used as efficiently as possible.

"We are contemplating a replacement facility and we don't want to build more beds to accommodate our inefficiency if there's a better way," she says. "If we could be more efficient, could we shutter units and operate on a smaller chassis?"

She adds that this question gained traction under the prospect of healthcare reform, where efficiency and quality is rewarded.

"We shouldn't put more into plants and operations than we need to."

That meant some extensive process re-engineering was in order.

St. Luke's is one of 14 hospitals (and three medical schools) which make up some of the 49 healthcare institutions that are part of the largest collection of clinical space in the world—Texas Medical Center in Houston. Even though the system has plenty of space for expansion outside the central downtown location of TMC, options for replacement and expansion are limited on the TMC campus. That forced them to make the necessary decision to improve processes to get more out of the space they already have, says Van Bree. 

GE Healthcare Performance Solutions was brought in to consult about ways to optimize the space and time constraints at the hospital. The project, as you might guess, is heavily populated by physicians, who found their time spent at St. Luke's was less productive than it might be. Though there are lots of components in the exercise, big gains stood to be made by doing a better job of patient care management and block scheduling for the physicians, Van Bree says.

"Some of the initial work has been on smoothing out variability in the elective operating room," she says. "It's six times greater than in our emergency room."

Physicians there preferred the first come, first served nature of scheduling elective surgeries, she said, but that wasn't working very well at St. Luke's—even with 42 total ORs available. Implementing block scheduling, which allows them to do several cases in one block of time, wasn't perfect either.

"Rooms were blocked 91% of the time. Optimally it should be 48%," she says. "We had the ability to add 5,000 patients by freeing up these blocks."

Physicians agreed to help find a solution that worked for all of them, and the institution.

"When you're talking with physicians about block scheduling vs. first-come first-serve, those are really difficult conversations," she says.

You might guess IT was involved here, and you'd be right. A sophisticated modeling software tool was used to weigh surgical demand against required resources, evaluate hundreds of thousands of potential scheduling scenarios, and allocate block time in a way that meets surgeons' needs while also accommodating new cases and flex capacity.

A team of physicians looked at many of the possible scenarios that the software presented, and collectively decided upon the most time-efficient schedule for the surgeons and the hospital as an organization. That helped with culture change, says Van Bree.

"They are willing to partner because it gives them greater control and from a leadership perspective, causes them to 'own' pieces of this organization," she says.

Concurrent work is progressing on moving patients efficiently through the organization, which should be both an employee- and patient-friendly effort. As Van Bree notes, the hospital "felt full" but actually wasn't.

By re-engineering the best ways for patients to be moved through the system, the goal was to improve patient care and satisfaction, improve staff satisfaction, standardize employee roles, and improve communications across departments, hopefully yielding better decision making and financial benefits, among others.

For example, Van Bree says, care areas should be better able to prioritize how they take patients. An inpatient might have a final appointment with radiology before she's discharged. Yet she still has to wait in line with many others who are ahead of her in the queue, which might mean that discharge is delayed by hours, if not a whole day.

"If that patient goes first, we might be able to free up a bed," Van Bree says. "There's no way to tee that up right now, but a big part of this project is to take away that white space where we're really not advancing patient care."

Not only that, but this kind of work is likely going to lower the cost of any replacement facility that gets built, because the inefficiencies that exist now won't be baked in, she adds. 

"If you are in an old plant you can't avoid the question of rebuilding, but there's an appropriate hesitancy for anyone considering big building projects right now. We're trying to make sure that we're getting improvements we need from operations and that we are not asking our board to fund inefficiencies in our system," she says. "If cost per bed is $1-2 million, the difference between a 750 and 650-bed facility…well there's a lot of difference."

No, they’re not going out of business, at least not the vast majority. But many of them have read the writing on the wall—which points to greater investments in affiliated services such as home care, clinics, physician practices, and nursing homes, among others—and are concluding that they are unwilling, and in most cases, unable, to invest in these pieces of the care continuum. Instead, they are making preemptive moves to affiliate with larger regional partners, thus sacrificing their independence. In short, standalone, independent community hospitals seem to be a quickly vanishing breed.

There are a multitude of advantages on the community hospital side of the deal. Of course, they gain the benefits of being in a larger network, which are vast. First, when dealing with commercial insurance contracts, they are able to tie into the contracting expertise of large systems, and more importantly, their market clout. They’re also able to tie into larger systems’ clinical (and financial) information technology systems, as well as their array of training expertise on these systems. In an era in which providers will increasingly be reimbursed based more on the quality of their care rather than the volume, this kind of implementation and training is essential. For the bigger partner, such affiliations expand their network and, let’s face it, give them a better stance at the negotiating table with the big commercial insurers at contracting time.

If you’re like me, you peruse the daily news looking for which hospital it will be today. Lately, if a day goes by without another announcement of some sort of affiliation agreement between a community hospital and larger regional player, it’s like something’s missing from my day.

Not that I take any joy or sorrow from reading about these deals, but they’ve become so commonplace. For those leading community hospitals, the affiliation environment is pretty good, especially if you control your local market. That won’t necessarily be the case in the future.

Although circumstances are entirely different, I see some of the same forces at play in this rush to grab market share that I saw back in the ’90’s when hospitals routinely spent millions buying up physician practices only to find later that controlling market share was hardly enough to make the acquisitions a success. Of course, the biggest difference between the buying spree of the ’90s on physician practices and the post 2010 rush to affiliate with community hospitals is the routine absence of cash in most of the deals I’ve seen. Governance issues aside, that seems to protect both parties should the deal not work out as they anticipate. That sense of caution was notably absent in the rush to acquire physician practices in the past.

Standalone community hospitals have been able to withstand big challenges in the past, but the fundamental restructuring of the reimbursement system seems to be a bridge too far. The injection of risk into the business equation for a community hospital appears to be the last straw. The last big cottage industry in America is going by the wayside, and the implications of that transformation are just beginning to be felt.

For now, patients might not see big changes. In many cases, the local hospital, despite the affiliation, is keeping its own name, and much of the work on transformation has less to do with what the sign out front says and more to do with the behind-the-scenes process and IT re-engineering I mentioned above. That’s a bright side of these changes. Another bright side is that the struggling community hospital gets to stay open indefinitely, although they are no longer in as much control over their ultimate fate.

Who's going to shop for healthcare in an emergency? How would you even begin to shop for complex procedures like heart surgery? Who's going to look for a discount on cancer treatment? Anything like that is probably going to meet and easily exceed your deductible anyway. And besides, saving a few bucks on treatment is probably the last thing on the minds of people suffering from these maladies—their family members, too.

Those are all valid concerns and I don't have a good rebuttal. But just because people still can't—or are unwilling—to shop for high-end treatment doesn't mean the idea doesn't have merit.  I've heard this argument for years, especially back when the federally endorsed method of reducing healthcare costs revolved around consumers shopping for care using their health savings accounts.

But what if shopping for healthcare focused on the little things we all need to access, such as primary care, prescription drugs, or other, less life-threatening and immediate procedures? That's where a little consumer involvement could actually work to improve quality and bring down costs.

What's changed in the past several years since the Bush administration touted HSAs is that most of us are paying more out of our pockets for our healthcare—a lot more—than we were at that time. Companies, including my own, are instituting high deductibles and high coinsurance requirements for their employees who have insurance. I get it.

But we're largely at the mercy of those who provide the care, and the fact that we're all paying a lot more for healthcare out of our own pockets hasn't translated to lower costs. But that may be changing as a host of companies are seeking to provide the kind of information that makes it easier to save money on routine care.

In some cases, these companies do the shopping for you—you just have to define the parameters, sort of like establishing your preferences and letting eBay do the searching legwork for you. 

Recently, I spoke with Howard McLure, who is former president of CVS/Caremark, about his new gig, which, you guessed it, involves getting consumers to shop for healthcare—sort of.

McLure is transitioning to become chairman and CEO of change:healthcare, a company that uses employers' claims data to help find better deals for employees on the healthcare that they have to pay for out of their own pockets. His isn't the only company that does this, but the idea sounds promising.

It works by comparing de-identified claims data across the client company to help locate better prices for primary care, dentistry, prescription drugs and a variety of other small-dollar healthcare expenses that can add up to big bucks over the course of a year. The larger the company, the better the data, and change:healthcare can even combine two or more companies' claims data as long as they share the same insurance network.

Let's say you pay $85 each time you visit the dentist for a cleaning. Maybe one of your colleagues—probably someone you don't even know—pays $60. McClure's company's database can let you know about the cheaper price if it fits within your chosen set of parameters—distance from you, quality, services offered--and lets you know about the option to save. You don't have to do it, but at least you have the information.

McClure acknowledges the bigger the employee pool, the more likely it is that his company can find more ways to save for beneficiaries. Right now, they're finding ways to save for about half the population for a given company.

"We're seeing very good engagement levels," he says. "About 45% of employees are taking advantage of the information," meaning, they're switching providers to find a cheaper price. He says the company is finding about $350 a year in potential savings for the average beneficiary. That may not sound like much, but if my company hired them to find these kinds of savings for me, you can bet I would take advantage of it. So will a lot of other people.

So while shopping for healthcare has miles to go before it's really effective, baby steps like these are starting to gain traction. It's about time.