Health Business Blog

Hospitals and health systems are always looking to boost brand awareness and attract new patients, so it’s not surprising that some sponsor high-profile medical screening buses to get the word out and bring patients in. I’ve always been dubious of this approach, which reminds me of garages that offer free 150 point inspections as a benefit to customers.  Obviously the garage expects to make back any cost of the diagnostic by uncovering new problems to treat. Hospitals aren’t that different.

There are downsides other than cost to unnecessary screening tests. Positive results can lead to invasive, dangerous and expensive follow-up tests along with anxiety.

One organization, Health Fair runs buses in the Washington, DC region that offers a package of five tests for $139. The US Preventive Services Task Force recommends against all five of these tests. Abnormal results of one kind or another are found in almost half of all patients screened. You can bet a whole lot of those are false positives or minor issues that are best ignored.

I’m gals to see Kaiser Health News go after this kind of story so people are aware that what looks like a friendly, innocuous service may be something less positive.

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By David E. Williams of the Health Business Group.

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This is the transcript of my recent interview with Cancer Treatment Centers of America CEO Steve Bonner.

David Williams: This is David E. Williams from the Health Business Group. I’m speaking today with Steve Bonner, CEO of Cancer Treatment Centers of America.

Steve, thanks for joining me today.

Steve Bonner: You’re very welcome, David. It’s great to speak with you again.

David Williams: What is Cancer Treatment Centers of America and how does it differ from other well-known cancer centers?

Steve Bonner: Cancer Treatment Centers of America is a growing chain of hospitals that specialize in and treat only cancer. We tend to see later-stage, more complex patients, because they get the diagnosis and stay at home until it becomes more complex. At that point they then, go looking.

We have as comprehensive and complete an array of technology and talent for traditional cancer therapy under one roof as you can find anywhere. What really sets us apart is our commitment to a holistic and an integrated style of care. The traditional therapy treats the tumor but cancer is not the tumor, it’s the malfunction of the basic immune system. Therefore we provide a very robust array of complementary therapies, which include nutrition plans, naturopathic intervention, mind and body medicine, spiritual support, exercise, Reiki, yoga, Pilates and pain management, which includes acupuncture as well as more traditional methods of pain management.

We integrate these therapies for every patient in a way that you  don’t see elsewhere. If you go to the finest cancer providers, you’ll be able to see a great medical oncologist and a cancer-trained nutritionist and naturopath. However, those professionals will never talk to each other. We structure a team of those professionals around each patient and that team stays with that patient throughout  the course of their treatment at  CTCA.

David Williams: I’m curious about how you think about the definition of quality in patient care because  a more holistic and integrated approach, is more difficult to measure.

Steve Bonner: Exactly. Our corporate DNA is grounded in the philosophy of patient-centric care. Of course, everybody says that, but we were created by an international merchant banker and a libertarian whose mother got cancer. Our founder set out to create something that structurally keeps us focused on the patient. As a result, when it comes to quality, the question we keep asking is, for each patient, what is the patient’s definition of quality and how are we doing in achieving that?

We have our own extensive measures of the quality of the experience. We measure and publish data from the patient point of view, using a Bain Net Promoter Score and also do the conventional Press Ganey Measurement. – We also include HCAHPS, Leapfrog and many others.

We believe that as an industry, we have a long way to go to really understand quality from the patient’s point of view. When we talk about HCAHPS and Leapfrog, they’re useful, but they’re more for the industry’s point of view than the patient’s point of view.

We have two major initiatives that are underway to try to help us better understand quality measures and then provide information about quality that we think can lead to some breakthroughs. One is a new piece of research that we’ve just released called the “The Cancer Experience”. It is a national study of patients and caregivers. The Cancer Experience is composed of a thousand cancer patients, a thousand caregivers, and family members of cancer patients all of whom are people who have been treated in centers across the country. This isn’t specific to CTCA patients although our patients are included.

The headline of this study that was surprising to us is that one in four of these patients and caregivers are dissatisfied with the care that they’ve received across the US. We note that 20 percent of these patients have left the place they went first for care and have gone somewhere else as they try to find the quality of care and the price of care that matches their expectations.

The survey goes on to point out that there are three major events or elements of care that really drive the dissatisfaction. The first is that patients know how complex the disease is, know how complex the treatment is going to be, and know how  challenging it’s going to be to understand it.  They expect and want us to provide them with a care quarterback the minute they come into the hospital that can stay with them throughout their care. A person that understands their disease understands what we can do and can help them navigate the system.

The second issue is that patients want an integrated care team to make sure that they get care for this disease that addresses the mind, body, and spirit, not just the tumor. The survey told us that 86 percent of the patients and caregivers wanted an integrated team, but fewer than 70 percent actually were able to have one.

The third major driver of this dissatisfaction is pain management.   It is easy to imagine how important that is to a patient and to a caregiver.  It was interesting that the caregiver actually felt more strongly about pain management than the patients did. Half the population in the survey said they did not get the pain management that they needed and wanted to allow them to be able to navigate their treatment and get to the best possible outcome.

The other major activity that we’re involved with is to try to help the industry and help us understand quality from a patient’s point of view.  In response to this we’ve created a partnership with the National Patient Advocate Foundation, which is not-for-profit. We’re underwriting a piece of research that will be presented a year from now, next April. It is another survey of cancer patients and family members that will allow them to define the cancer value index in their terms.

It’s basically  trying to create the JD Power of oncology, where the association of research will conduct this research, they’ll publish the research and then, they’ll continue to manage it in a way that will allow providers to give them our performance information. They can then publish it in a way that will make it much more comparable for patients and allow them to more intelligently navigate the industry as they seek a combination of quality, price and as a result, value.

David Williams: I’d like to ask you more about the role of competition in terms of improving quality. You mentioned that your founder comes from a libertarian background and merchant banking. And of course you’re a for profit organization. In lots of places in the economy, competition drives quality, performance and value but not necessarily in health care. What role does competition play in driving quality in health care, both in oncology and more broadly?

Steve Bonner: Competition is one of the most powerful drivers of quality, cost and value that is available to us. An empowered consumer with choice will walk, talk and teach us what real value is. If we then compete based on those terms, we’re going to see quality naturally go up and price naturally come down.  Even in health care today — LASIK or elective plastic surgery — where it’s up to the patient to decide and pay you see continued improvement in the quality and in the technology. And you can see the price continuing to come down.

The way we’ve constrained competition in health care is a major factor in how expensive care has become and how elusive true quality is. That’s part of the reason we’re sponsoring these two significant efforts to engage the consumer to teach us how they want to define quality.

David Williams: In most markets, including ones you’ve described, there’s usually a market price for something, and the supplier sets their prices and customers either pay it or they don’t. Health care is also a little different where you have commercially-insured patients and you have Medicare and Medicaid patients. Medicare,  in particular, will tend to pay a lot less than what the commercial patients are paying.

In an area like oncology, what impact does that have on providers and on patients? What are the policy implications of this often wide disparity between the commercial reimbursement rates and what government programs are paying?

Steve Bonner: The implications are profound. I may back up a step and say that if we want competition to control the market, then we have to enable that competition with much better information, including information about price.

David Williams: Let me ask you about the recent Reuters Special Report that I’m sure you’ve seen. It was taking a look at your company’s claims that survival rates are higher for your patients than for other patients. It concluded that those claims couldn’t really be substantiated because there were differences in your patient population versus those you were comparing it with. Can you just provide some commentary on how you look at this issue more broadly and address some specific questions that came up in that Reuters Report?

Steve Bonner: We heard that these reporters were working on a story and we reached out to them and invited them to include us in the dialogue, which ultimately they did at some level. We invited them to come and visit our hospitals and talk to our patients and  understand the patient experience, which was part of what they were writing about. We explained to them what we’ve done with the publication of our outcomes and the rationale behind it and the evolution of it going forward.

We did tell them that all the data that we published on our website on outcomes is vetted by an independent research team at Washington University and offered them the opportunity to talk to the research team. They declined to come and  look at it. In my opinion, they wound up drawing unsustainable conclusions and making observations that simply aren’t supportable as they presented them.

We’re either the first or the second or the third in oncology to put any outcomes data on our website — but we publish all the outcomes on analytic patients who come to CTCA. These are patients who had not been treated elsewhere. We publish that by length of life, quality of life, match to location and stage of disease. It’s very clear that’s what is published.

The other way to come at it is what we don’t publish. We don’t publish data on the patients who have been treated elsewhere before they come. The question is why, and the reason is because we haven’t so far figured out a good frame of reference to offer people. With analytics of the disease, we have the SEER and NCI database and that’s what we use as a point of reference.  We think it’s fairly comparable to this segment of our patient population.

Where we have a fourth-stage pancreatic cancer patient who also has diabetes and a heart condition and has been treated in some very unique way in two or three organizations, to just publish their length of life data, we don’t think would be helpful to patients. We haven’t published that. We’re in the process of relooking at that and maybe we just need to put that out there and then, we’ll take on the questions as they come.

Some of the organizations that the reporter quoted in criticizing our methodology are organizations that so far had not published one statistic with respect to their own outcomes. They don’t publish HCAHPS data. They don’t publish Press Ganey data. We ask ourselves how valid and relevant and reliable are these as critics?

We do have a unique population and that’s a fair observation. We talked about the major elements of it. They are very engaged patients. Most are patients who have been diagnosed and treated elsewhere, they’re not happy, and they’re willing to travel. Our average patient travels 250 to 300 miles to come to us for care. These are people that really are in the game and are going to do what they need to do to find a cure.

They tend to be a more advanced stage population than  others. The article suggested that we culled out from inquiring patients those who were more advanced with their disease and that’s absolutely unsupportable.  We see many patients who had been told by MD Anderson, Sloan-Kettering, Cleveland Clinic that there’s nothing more than can be done for them at those institutions and to go home and get their affairs in order. We take those people in. We can introduce them  to patients who have heard that same thing from those institutions and others three years ago, five years ago, ten years ago.

We’re here for that kind of patient and do everything we can to bring them in. Every patient has to navigate their insurance structure, and that’s what culls out patients, not CTCA.  When the patients want to come to us, we’ll work very hard with their insurance company and with their employer to try to make sure everybody understands the situation. We look at what other options might be available for the patient and try to open doors that might otherwise be closed.

We see some insurance companies and some employers being much more flexible with these patients who clearly have no options elsewhere.  If a patient’s in an HMO and they’re not willing to let them opt out of the HMO into some sort of a PPO coverage, there’s really not going to be a way for them to come to CTCA. That’s the insurance market operating, not us culling patients.

David Williams: As you look at the next three or five years,  do you see any expansion opportunities? Is it putting facilities in different geographies from where you’ve been? Is it offering new kind of services? Where do you see the company heading over the medium term?

Steve Bonner: The future of health care is a really an exciting future to behold, and especially in oncology. For CTCA, we are looking at trying to make ourselves more conveniently accessible to patients. In the last seven years, we’ve gone from one center to five centers and we’re looking at a sixth center. We’re looking at the possibility of some less intensive centers that  we can put many more of them around the country and offer cancer information, central diagnostics and routine treatment. The therapeutic future may be even more exciting than that to us.  We think that the next major breakthrough in oncology is clear and that’s going to be understanding the disease at a genomic level and then being able to match known therapies much more precisely with the genomic abnormalities that a person’s expressing.

We’re working very hard on genomic innovation. Today, when you get cancer, a tumor shows up in one part of your body, insurance company providers go to an FDA-approved drop-down menu that says “if you have that cancer in that body location, this is the treatment that’s performed best in large population, placebo-controlled double-blinded studies”, and so you should get that. Every insurance company will pay for it and if you stay in network they’ll get it for you at a 40 percent discount.

The reality is that those large population studies produce the best tumor response in maybe 40 percent of the population. We’re prepared to pay for 100 percent of the population to get the therapy even though we know statistically only 40 percent are going to respond well.  As we dig underneath that, we find that your pancreatic cancer and my liver cancer may actually be driven by the same genomic abnormality, but our systems express tumors different., You’re going to get one therapy and I’m going to get another therapy. If we understood it genomically, we’d both get the same therapy and avoid a lot of unnecessary therapy that we deliver through the system today.  This is one way to take significant cost out of oncology care and really accelerate and enhance the quality and effectiveness of care. That’s the most exciting thing we see in the future.

David Williams: I’ve been speaking today with Steve Bonner. He is CEO of Cancer Treatment Centers of America. Steve, thanks so much for your time.

Steve Bonner: Thank you, David. Take care.

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Stephen Bonner is CEO of Cancer Treatment Centers of America (CTCA). In this podcast interview he discusses CTCA’s integrative approach and its commitment to measuring and reporting quality. He also takes on a Reuters report that concluded CTCA’s claims of higher survival rates could not be substantiated, and questions the credibility of CTCA’s critics.

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David Williams interviews Cancer Treatment Centers of America CEO Steve Bonner [ 20:28 ] Play Now | Play in Popup | Download

Hospitals have many devices collecting data on patients, but until recently information from those devices has not been routinely integrated nor stored in electronic medical records. In this interview, Stuart Long, Chief Marketing and Sales Officer of Capsule explains the benefits of medical device integration and how it works in a hospital.

Why is medical device connectivity important, and what benefits does it bring to the patient?

Rapidly becoming a priority for many hospitals, biomedical device connectivity to the hospital network—or medical device integration (MDI)– enables medical devices to transfer patient data from the point-of-care over the network into an electronic medical record (EMR) system or other charting systems. Device integration delivers patient data to clinicians in near real time so that information supporting patient care decisions is delivered timely and accurately.  Without MDI, patient data, particularly vital signs, is transcribed on paper charts and the recording is duplicated by manually having to key the data into the patient’s electronic record. MDI helps assure data accuracy by eliminating manual transcription errors while relieving caregivers from burdensome manual tasks, enabling more quality time with patients.  The bottom line is increased patient safety and care.

Why is it important to automate the collection of patient data (i.e. vital signs) and how does this improve the quality of data entering the EMR?

End-to-end automation of patient data collection ensures accuracy and precision.  Full automation removes potential error points along the way as device information is sent to the EMR or other systems.  For example, as I mentioned before that many caregivers read data from a device, manually record it and then input it into the electronic system.  From an administrative standpoint, the need for absolute accuracy of data is greater than ever before.  In addition, having data in electronic format is essential to ensure the full realization of a complete electronic record, which enables data exchange with other hospital IT systems and access to this information hospital-wide. Again, from a regulatory and reimbursement standpoint, the importance of this electronic format is increasing as Meaningful Use (MU) guidelines become more defined.

What happens to patient data as it moves throughout the hospital? How is that data being used?

As patient data is collected through electronic means, it is aggregated from software or hardware, analyzed by the connectivity software, and translated into a format appropriate for the hospital IT system receiving the information.  Various hospital departments—whether the ED, OR, ICU or med-surg–may output device data in disparate formats, often completely proprietary formats.  That data then must be translated into a standard format for the EMR and perhaps reinterpreted once again for compatibility with specialized departmental IT systems.  As each new department inputs information, the data is normalized as required and translated for the needs of specific hospital IT systems.  In that way, device information can follow the patient through the hospital, wherever it is needed.

What are some of the differences across care units in the hospital? How does that impact the technology being used?

Workflow varies greatly among various care units—the ED, OR, med-surg and step-down, for example, and also varies by hospital.  Med-surg units often have many beds with a limited number of devices shared among them on mobile carts.  Intensive Care, by contrast, may rely on a greater number of devices, which are fixed in location and associated with a particular bed. A quality MDI system seeks to reduce the complexity of its technology by supporting the existing workflow already in place in a particular setting.  Capsule has different hardware and software solutions to support various settings and workflow requirements. Some are wall-mounted units that accept fixed-position devices and are already associated with a specific bed for continuous data collection. Another solution would be a mobile device interface for equipment with no fixed location, which must be associated with the individual patient for periodic data collection.  Data must be validated, and in some settings, a nurse requires flexibility about the timeframe care patients may require immediate attention before caregivers have time to accept data.

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Interview conducted by David E. Williams of the Health Business Group.

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A new JAMA article (Relationship Between Occurrence of Surgical Complications and Hospital Finances) by a variety of health care wonks including some of my former Boston Consulting Group colleagues demonstrates that hospitals make more money when surgical patients have complications. The article is useful in that it documents the extent of the situation but the situation is actually pretty obvious and well understood.

An author described work at a hospital to reduce surgical complications. According to the New York Times, “the team was stunned to realize that lowering the complication rates would actually cost the hospital money.”

Stunned?

In a fee-for-service model, hospitals get paid for what they do, not what outcomes are achieved. So if something goes wrong in surgery the hospital usually gets to bill for the ICU, another surgery, extra days in the hospital, etc. Unless those services are unprofitable then of course the hospital will make more money from cases where those resources are used.

If a factory screws up its production process, it has to spend more money to rework the product, but it can’t sell the final goods for more money. If it messes up badly the work in process may need to be scrapped and the product can’t be sold at all. But a hospital can often charge for its rework (avoidable complications) and the scrap (deaths caused by errors).

I described the situation last year in Reducing surgical complications: How to make it happen faster.

By David E. Williams of the Health Business Group.

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This is the transcript of my recent podcast with J.P. Fingado of API Healthcare.

David Williams:  This is David E. Williams from the Health Business Group.  I’m speaking today with J.P. Fingado, President and CEO of API Healthcare.  We are at HIMSS in New Orleans.

What problem does API address?

J.P. Fingado: We’re trying to solve several problems.  The first is around quality of care, so we seek to put the right people at the right place at the right time to achieve the best possible outcome for the patient.

The second piece is helping hospitals control their cost and optimize the use of labor.  So if we actually optimize across everybody in the hospital, across all their facilities through the continuum of care, we’re saving the hospitals millions of dollars through the deployment of their staff on an annual basis.

There’s a third piece that’s also very important, which is improving that satisfaction of their entire workforce. Allowing them to have more control over their schedules, over their interaction with their human resource system leads to happier employees, which in return, increases productivity.

Williams:  Here at HIMSS there’s certainly a lot of discussion about electronic health records and health information exchange. Meanwhile you have a couple of things that sound like variants on those.  You’ve got not an EHR but an EER and not a health information exchange but a healthcare workforce information exchange.  Can you describe what those concepts are and how they fit in to the goals that you’re trying to achieve?

Fingado: The electronic employee record is a single repository of everything about every single health worker in an institution.  We’re actually tracking before they even come on board.  We’ll start the data collection at the recruiting phase to understanding the competencies and the scenarios and the environments that workers have been in prior to joining an organization.

Once they come then we’re tracking all their growth inside of an organization.  We’re tracking where they work inside of a hospital, the time that’s being tracked, all their HR information, all their training, all their performance reviews.  We ultimately go to full succession planning.

Putting these millions of data points into a single record allows the hospital to effectively deploy those people and put the best people on the field at any point in time.

The other piece that we brought to market from an innovation standpoint is the healthcare workforce information exchange. We take all these records –imagine in a hospital two or three thousand people and the millions of data points– and we optimize that across the continuum of care and share the information across every facility inside of a hospital.

We’ve got a hospital customer, for example, Advocate Health Care, which over 200 locations in their network with tens of thousands of people that we help them optimize.

Williams:  Interestingly, you seem to be combining clinical information about patients in the hospital with this EER concept. If a client is using your system, how much of a difference can it make for the patients that are in the hospital?  Is it just a minor or incremental improvement or do you see something that’s more dramatic. And if so, how could you measure that?

Fingado: So scheduling a nurse is not like scheduling a waitress.  You can not just give every nurse three patients and call it a day.  There’s a huge benefit when you can match up the needs of the patient to the expertise of the nurse.  So think about it. If you are in the ICU and there was one nurse that had treated 50 patients with the exact ailment and another nurse that treated one, which nurse do you want?

It’s pretty obvious.  So when you start to do that you really drive higher quality across the board, a better outcome for the patient. Now you’re talking about huge results for the organization.  With reform, reimbursements are going to get tied to quality.  Poor quality will drop reimbursements.

So now we’re not only saving the money on the expense side, we’re actually increasing the revenue of the organization, now making it a healthier environment, which in turn helps patients as well.

Williams:  You’ve been describing the tracking of nurses and others from the time they are hired into the organization and maybe even beforehand. But a lot of these health care organizations are a little more complex than that. A lot of them use agencies or other sorts of outside resources.  So how do you address that situation where you have many personnel that are not actually employees of the hospital?

Fingado:  That’s a unique thing that we do that nobody else in the industry does. We don’t think in terms of employees.  When you look at a hospital you’ve got the full-time employees and part-time employees, but you have volunteers, you have contractors and you have contingent workers.

When we put in the system we’re putting in the system for all the health care workers in an institution.  If somebody calls in sick a nurse manager or a manager of any department can look at all the available resources in their department, they could look in the float pools, they could across the entire organization.

But with our systems they can also look at any contingent staffing companies that are in their preferred network and it will show them just the resources that fit the need based on licenses, competencies, performance ratings, as well as cost.  And for the first time, a manager can make an instantaneous decision about picking the right resource, not just their full-time employees but anybody that can provide the highest level of care to the patient.

Williams:  I want to ask a broader policy question that relates to what you’re doing. We hear about the shortage of nurses and in particular about baby boomer nurses that are going to retire, but at the same time we also hear that nurses graduating from nursing school are actually having a hard time getting started in the profession.

So you could see a situation where you’ve got a lot of inexperienced nurses who don’t get experience and then a lot of nurses that eventually retire. You also have some people who will come in and out of the workforce. It all seems very dysfunctional. Does what you’re doing contribute to getting nurses into the funnel and helping them to get experience?

Help me understand this combination of a nursing shortage overall coupled with the difficulty a new nurse has getting hired.

Fingado:  A very astute observation.  So that’s actually a big reason why we’re seeing a lot of demand for the systems. Hospitals are bringing a lot of the nurses in who don’t have a lot of experience and what they can do as part of the system is match those nurses with the experienced nurses, put them in scenarios where they can really learn and get up to speed quicker, and then over time starting to move them to more independent roles where they’re learning and training on different types of patients going forward.

It’s a huge issue and one reason why hospital administrations are starting to make a big technology investment in workforce management. They recognize that there’s going to be a big shift in the workforce over the next decade.

Williams: I’ve been speaking today with J.P. Fingado, President and CEO of API Healthcare.  We’re at HIMSS in New Orleans.  J.P., thank you very much for your time.

Fingado:  David, thank you and I hope you have a great rest of the show.

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You should read Dr. Scott Gottlieb’s (The Doctor Won’t See You Now. He’s Clocked Out) opinion piece in the Wall Street Journal. He argues that ObamaCare is making independent physician practices obsolete by forcing physicians to work for big hospitals as part of Accountable Care Organizations (ACO), is  imposing high costs for information technology on those who try to remain independent, and that the Administration’s policies will have the ironic consequence of driving up costs since employed physicians are less productive.

There’s a lot of truth in the article. As I have written recently, fees sometimes rise when hospitals buy physician practices and tack on facility fees. And in my prediction for 2013 published by InformationWeek I predicted that physicians will struggle to stay independent.

But although I mainly agree with Gottlieb’s observations, I’m more optimistic than he is, and less eager to point the finger at ObamaCare. In particular:

• The trend toward hospital employment has been going on for a long while now, as Gottlieb acknowledges. One could say ObamaCare encourages this trend but from my perspective the bigger factors are the desire to join with a bigger entity to negotiate better rates with managed care, a generational shift as younger doctors decide they want balance between life and work (especially women, who now comprise the majority of medical students), and the rising overhead involved in running a practice. Ironically, physicians I’ve spoken with have cited the cost of health insurance for staff as a reason for joining up with the big boys!
• ObamaCare does not require anyone to be in an ACO and does not require them to be run by hospitals. Physicians could organize their own ACOs and I hope in the future more do, even if that hasn’t been the way things have gone so far
• Health IT is a drag on small office but also for big hospital based systems. Those inefficiencies will take a few years to work out but I’m optimistic that a new generation of systems will empower the small physician practice, the way technology has made it possible to operate smaller professional services firms in consulting, law and other fields
• Costs are becoming a bigger and bigger focus, and the country just won’t tolerate health care prices that go up and up. The facility fee issue and Steven Brill’s article in Time on costs are two examples. It’s commercial health plans, not government programs, that have been tolerating higher costs. Buying up physician practices may help hospitals negotiate hard with commercial health plans but Medicare and Medicaid are not going to be impressed. In the long run –maybe 10 years– hospital systems that fail to generate greater efficiency from buying up practices will lose ground to new types of entities, especially those that are virtually integrated through technology. As Gottlieb pointed out, we’ve been through the cycle of physician acquisition by hospitals before, and it was reversed due to lagging productivity
• ObamaCare represents a great big target to shoot at, and easy to criticize in a vacuum. But we have to compare it with what came before, which was hardly a panacea.

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Yesterday’s Boston Globe article (Hospital charges bring a backlash) was spot on. Reporter Liz Kowalczyk nailed the topic:

• Hospitals are adding facility fees in the hundreds of dollars for many visits to hospital-owned physician practices, even when those practices are nowhere near the hospital
• Facility fees are becoming more common as hospitals purchase formerly independent physician practices and tack on the fees
• Patients are pushing back. One reason is that more of them have high deductible plans that force the patient to bear more of the cost
• Insurance companies are aware of the issue but have generally been allowing the fees

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#HIMMS13 in New Orleans was quite literally dizzying. Tens of thousands of health IT vendors were spread across acres and acres of floor space. I only had a day and a half at the show but made the most of it by interviewing several interesting companies. Over the next couple of weeks I’ll be posting interviews and stories from the event.

I really enjoyed meeting with J.P. Fingado, President and CEO of API Healthcare, a health care workforce management solutions company. In this podcast interview, J.P. explains how API helps get the right people in the right place at the right time, how it optimizes the use of labor for hospitals, and how it improves worker satisfaction. He introduces the concept of an EER (electronic employee record) and HWIE (healthcare workforce information exchange).

I was impressed by the inclusion of external staffing agencies in the solution and how API matches workforce competencies with clinical needs.

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David Williams interviews API CEO J.P. Fingado [ 7:09 ] Play Now | Play in Popup | Download

This is a transcript of my recent podcast interview with Anne Weiss of the Robert Wood Johnson Foundation.

David E. Williams: This is David Williams, author of the Health Business Blog.

I’m speaking today with Anne Weiss. She is Quality/Equality Health Care Team Director and Senior Program Officer at the Robert Wood Johnson Foundation.

The Foundation recently released a report called The Revolving Door: A Report on US Hospital Readmissions, which uses data from the Dartmouth Atlas Project to show that many Medicare patients are readmitted to the hospital after being discharged. The report also includes results from interviews with patients and providers to provide insights into how to reduce avoidable readmissions.

Anne, thanks for joining me today.

Anne Weiss: Thanks for having me.

Williams: Anne, consistent with other Dartmouth Atlas Reports I’ve seen, there’s a lot of emphasis in this one on regional variation. So, my question to you is how significant is this regional variation for readmissions and to what extent do the outliers actually represent best and worst practices that should be emulated or avoided?

Weiss: We do see pretty significant variation in the rates of readmission for Medicare patients who go home after identical surgeries or identical medical problems. There are very different experiences around the country. This is 2010 data and we saw readmission rates for surgical patients ranging from 18% in the Bronx to 8% in Bend, Oregon. For medical readmission, again, 18% in the Bronx down to 11% in Ogden, Utah.

So it’s significant variation. This study is not designed to tell us about the practice patterns in these areas. We looked strictly at admissions and post-acute care. We do know that there are a lot of different reasons behind this kind of variation. You could see differences in the underlying health status of the patients. You can see differences in the quality of hospital care including discharge planning. You can see best and worst practices in care coordination. And this is really important; you can see a lot of differences in the availability of primary care locally and the availability of hospital beds.

We know that the Dartmouth Atlas has already demonstrated that the local supply of hospital beds drives practice patterns. So other things equal, I think we can assume that when there are more hospital beds, patients are more likely to be admitted and readmitted to the hospital.

So, the short answer is we don’t learn a lot about what the best and worst practices are from looking at the Dartmouth data. But it does tells us it’s a local problem; and our emphasis is on helping people at the local level look at their market circumstances and talk about solutions that will work for them.

Williams: It looks from the report that there’s been only limited progress on reducing readmissions, even though readmissions are something that people have at least been looking at for awhile. And it also seems like some of the efforts that looked promising initially have not proven to be sustainable. I realize it’s 2010 data, so maybe things have changed from there. I’m wondering whether there are examples of programs or approaches that had been shown to work well over extended periods of time.

Weiss: When we released the report, we featured a couple of models that do seem to have been picked up widely enough that I think it gives us hope that they can sustain their progress.

One is the Care Transitions Intervention, widely associated with Eric Coleman, a physician at the University of Colorado. It’s a four-week program with a transition coach who helps patients with complex conditions manage their medications and helps them know what to do when their condition gets worse. This has been picked up by about 750 organizations, including 34 who are a part of a major Medicare initiative, the Care Transitions Program. I have not seen specific data, and obviously, it hasn’t been years since this is in place. but the degree to which it has been picked up is pretty promising.

The other program that we featured is the Transitional Care Model developed by Mary Naylor (a nurse at the University of Pennsylvania) along with her colleagues. They provide very comprehensive training in the hospital and then follow up at home for chronically ill high-risk older patients. They use transitional care nurses. They have the skills of a nurse and the care manager and also a patient advocate. I know they’ve had a lot of very promising conversations with health plans and others. So again, I think that’s a sign that they are poised for the kind of sustainability you’re asking about.

I do want to make one other point about some of the programs that we’ve seen developed in communities that are involved in the Foundation’s signature initiative, Aligning Forces For Quality. This is the Robert Wood Johnson Foundation’s major effort to improve quality and reduce cost in 16 targeted markets around the country. And we’ve seen initiatives in places like Cleveland, Memphis, Maine and Oregon that haven’t been in place for a long time. We don’t have data that say that they’re sustainable, but the fact that they’re embedded in a larger community effort where there’s a great deal of transparency is promising. In many of these communities, there is a publicly available report online that compares hospital readmission rates.

They’re in communities that are working on payment reform, unbundled payments. They’re in communities that are working hard to build quality improvement infrastructure and to engage patients and families in demanding better care. I think that offers a lot of potential to sustain a good care transitions effort, although I can’t say today that we know that all these efforts will sustain themselves.

Williams: What can you say about individual patients and their families or caregivers who are perhaps in a region of the country that has above average readmissions, whether they’re in the Bronx or somewhere not quite as much of an outlier? Is there anything that an individual patient can do even in places where such programs are not in existence? And is there any evidence or do you have a sense of whether there are certain patients, perhaps those with higher levels of education or income, that are in a better position to make an impact on whether they are re-admitted?

Weiss: I don’t know from this study. We don’t know a lot about the specific characteristics of the patients. However, I think with rates that are this high, it’s not a problem that’s confined to patients who have low literacy or low incomes. I think if we talk about some of the things that patients and families can do, which I’ll mention in a moment, it suggests that these are things that can be done in a variety of socio-economic circumstances. So I don’t think it’s wholly dependent on family income or education level, although that helps.

The single most important thing we tell people to do is to ask questions, not to be afraid to bother the doctors and nurses and pharmacists, to keep asking until you understand the answer, and when you do get an answer to say it back, to repeat the answer to make sure you’ve understood it.

The second major area is to leave the hospital with a detailed written plan that covers two things — medications and appointments. So, a written list of medications with instructions about when and how to take them and a written list of follow-up appointments. The appointments are very important. If people have trouble making appointments or they don’t have a doctor, a family doctor, or the right specialist to go to, you can ask the hospital for help. And for both of these things, the medications and the appointment, I think it’s really important to involve a family member or a friend to make sure that they understand what could be done and they can help with things like transportation and making sure that you keep those appointments.

The last thing we tell people to do is to know what to do if you don’t feel well. Know the danger signs and know what you’re supposed to do if your symptoms got worse. I think it’s obvious that these things are more challenging for people who have low literacy or low health literacy. But I think all of them are things that any patient and family can try to become more engaged in.

I also want to mention that we have a great many tip sheets and other resources for patients at the website we set up for this initiative, which is called CareAboutYourCare.org. There’s a lot of information there that is really helpful for people from a very broad range of backgrounds and circumstances.

Williams: For a patient or a caregiver who is not currently contemplating a hospital visit, are there things that can be done perhaps structurally, and not just behaviorally, to try to make it less likely that a readmission would be needed? So for example, does it matter if a patient picks a primary care physician who practices as part of an integrated delivery network? Is there a difference in readmissions if the primary care practice uses hospitalists? Does it matter what type of health plan is used?

Weiss: Intuitively, it does seem that being part of an integrated system, your doctor being able to see you in the hospital, that those things should make a difference, but I have not seen data on this.

I will say that we conducted extensive interviews with patients and providers as part of the study and we did hear that the use of hospitalists can lead to more fragmented care, because the doctor isn’t always glued in to what happened in the hospital. That doesn’t mean that hospitalists are bad but it may mean that an intervention has to have an explicit step of getting the information back to the primary care doctor. And watching my parents in the health care system, I can’t think of how many times somebody threw a clipboard on their feet in the ambulance, and that was the extent of the information transfer.

Again, I haven’t seen information that compares the experience as patients in an integrated system or not. That does seem appealing, although we hope anyone who follows the weekly story about the safety implications of electronic health records can tell you that even in a completely integrated system, people miss pieces of information that were answered in one clinical setting and are relevant in another. So I don’t think you can let your guard down just because you’re in an integrated system. But you’re right, it’s promising.

And I know you said you wanted structural answers and not behavioral ones, but in my heart, I don’t think at this point in our health care system that there is a substitute for people understanding their conditions, understanding the behaviors that put them at risk, getting information that was proven to work, talking to the doctors, participating in making informed choices. And I don’t think we have the health care structure in the market yet that allows us to stop behaving that way as patient and consumers.

Williams: Fair enough.

So this sounds to me, Anne, like a problem that’s big, complex, perhaps even intractable. But the bright side of that might be some opportunities for entrepreneurs who are looking at ways to address elements of this readmission challenge. Any thoughts that you have for folks that are contemplating businesses in this area about where they might want to point their compass?

Weiss: A couple of things. I think the study does tell us that this is a local problem. And one thing we heard very strongly during all the public events was that you don’t pick something up in one market and just turn the key and it works in another market. Reinvention — what was it that somebody said — replication is reinvention. So, I think it’s important for entrepreneurs to think about that local market customization. That’s one point.

I think there is room for entrepreneurship across the continuum, whether it’s home care, whether it’s alternatives to the emergency department in the middle of the night, whether it’s new mobile technology. We heard from a patient who had a PDA that allowed him to answer five questions about his breathing condition every day; his nearest kin could monitor his status from afar and see how he was doing. So you could see all kind of mobile apps that could do that.

I think we have a payment system right now in this country where there’s a lot of financial rewards to a lot of people from the admissions. So for an entrepreneurial solution to work, it’s going to have to pay better or differently from readmission. The Medicare policy for readmission will start to rebalance that equation, but I think that’s a challenge.

The last thing I want to say is probably a little provocative to say to your readers. But I will say it anyway. I’ve been interviewed frequently about things like the company that provides care coordination to large employer groups. “If you get cancer, our company will come in and manage all your appointments and help you keep track of all the billing and everything.” And to me, that’s a symptom of what’s wrong with our health care system. And people will hold it out like, “Isn’t this great that we’re helping patients.” And I think that is true. I do think that a lot of the entrepreneurial opportunities have a lot of potential for improved care. But the problem we’re seeing here is a bad problem and my hope would be that we have a health care system that is patient centered enough that we don’t always need entrepreneurship to cure the ills that shouldn’t exist in the first place.

So I have mixed feelings about it but I do think that there are a lot of opportunities in the short run to make things better for patients and family.

Williams: I see on the motto of Children’s Hospital things like, “Until there’s no more childhood illness.” I think the children’s hospitals are busy trying to put themselves out of business. But they have no real fear of that happening in the near term. This may be something similar.

Weiss: Right, I mean it’s sort of like the argument we often have on primary prevention. And yes, we definitely can prevent a lot of chronic illness, but most cases of cancer are not preventable. We don’t know enough about them to prevent them. It’s a lot of things, so we still have a lot of room to make our health care system perform better and meet people’s needs. Some of the best opportunities right now, I think, are coming from innovative entrepreneurs.

So, in the short run, I think there is room for that. I just think it’s important for us to also keep track of the overall impact of the system on patients.

Williams: I’ve been speaking today with Anne Weiss from the Robert Wood Johnson Foundation. We’ve been talking about a new report on hospital readmissions and about RWJ’s Care About Your Care Initiative.

Anne, thank you so much.

Weiss: Thanks for having me.

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