Wednesday, July 25, 2007

The Toxic Side Effects of Change

It is obvious that significant change in the U.S. health care system will be required to correct the quality inefficiencies and simultaneous paralleling rising cost that we are observing today. This redesign also must be part of any successful presidential candidate’s plan, since the voices of change (government, business owners/employers and now patients and their families), are yelling their loudest in decades that both the quality of care and its related cost are unacceptable.

However, with change—whether it be in the clinical arena where treatments are being modified constantly, or in the administrative arena where processes and procedures must be updated to address these redesign needs—toxic side effects of change are inevitable. Therefore, it is prudent for us as health care leaders to predict these toxic side effects in advance so that when they occur, we will not have to face the ever-oppressing question, “Have we made a mistake?”

Such an example in the clinical arena would be the hair loss that occurs in a cancer patient when we are giving them what we hope will be curative chemotherapy. After two weeks of chemotherapy when we walk in to a patient’s room and find him or her bald, we do not say, “Oh no, what have we done?!” We rather say, “Oh, the treatment is working!” In this way, the toxic side effect of treatment proves to us that our ends are being achieved and the patient’s body is undergoing changes as a result.

We must apply the same logic in the administrative decision-making processes we undertake each day to facilitate the changes necessary for creating excellence. In this way, when we observe these side effects, we can say, “Yes, our strategies and initiatives are making a positive difference.”

One example of this would be CHRISTUS’ opening of many urgent care clinics (most are located in Mexico). Clearly, in advance of these openings, we predicted that a toxic side effect would be pushback from some physicians because they believe—inappropriately so—that we are providing poor quality of care and taking patients away from their practices.

Indeed, we have seen this pushback from the American Academy of Pediatrics and now the American Medical Association. The reality is that these clinics, staffed in Mexico by physicians and by nurse practitioners in the U.S., are providing patients with access to care for a limited number of illnesses which are carefully managed by evidence-based protocols that have been designed with strong physician input. Therefore, in no way has quality been decreased.

In fact, quality of care has been enhanced because patients can get access to care more quickly in the course of their illness and therefore more serious side effects can be prevented.

In addition, these clinics are open on evenings and weekends when most physician offices are closed. Physicians are always given the opportunity to work in our clinics, but they obviously must accept the salaries which make these clinics cost-effective. This payment level is readily acceptable and in fact is the standard for physician reimbursement in our international operations. It has been our experience that in America, physicians are not willing to do such.

In addition, we find very few physicians in America who are willing to open their offices in the evenings and on weekends. If they are willing to do so, we would be happy to partner with them to provide our urgent clinics in a joint venture methodology. We must always be willing to joint venture with physicians when they share our mission, vision, and values, and our goal is always to create win-win physician health system alignments. Working collaboratively with physicians has been and will always be a necessity for an excellent health care delivery system.

Another toxic side effect of these clinics is physicians’ fear of losing patients. In fact, the contrary is true in our clinics, where we generate primary care and specialty referrals for patients who do not meet the clinic criteria or do not improve with the therapies that are instituted and therefore require specialty consultation. So, in fact, we like to partner with both primary care and specialty physicians to provide a second level of care if it is necessary.

So as is often the case when changes are made, toxic side effects quickly make themselves known and in fact may turn out to have positive responses rather than negative effects. This of course does not mean that we overlook debriefing to decide what has worked and what has not, but identifying these toxic side effects beforehand will prevent Monday morning quarterbacking, feelings of “Oh my goodness, what have we done?”, etc. This is why before any significant change is made, considerable time and reflection should be spent determining the toxic side effects of a decision so that when they become apparent, there is no second guessing or scrambling to cater to opposing voices.

Wednesday, July 18, 2007

Health Care Reform – Who Should Come to the Table?

Health care reform is not a new topic; different groups have been talking about it for the last 20 years, but are now becoming louder and both more insistent and consistent.

The voices calling for change in health care have typically been the following:
1. The government: those who regulate and fund Medicare and Medicaid. Although governmental representatives should have a place at the table for this discussion, I believe that the most effective and logical solutions (those that work in practice and not just in theory) must be ultimately formed by experts who don’t have hidden political agendas and have worked in the health care field. These are the people who know best how to bring about the changes which are necessary.
2. Employers. When I worked at Henry Ford Health System, the cost to insure one employee at Ford Motor Company exceeded the cost for steel for one automobile. Insurance costs for employers continue to rise, and so they need a voice, especially as long as they are expected to foot the bill for much of the insured health care in America.
3. Patients and their families, long-term care residents, etc. Many of these are self-pay or must provide increasing insurance co-payments when receiving health care. Therefore, they are now stepping up to plate and saying, “I need to be heard.” As they are at the center of this discussion, it seems most important that they have the opportunity to participate.

As these groups gather around the table and embark on this ambitious journey, they should keep some additional things in mind.

First, do we have the resources to provide truly universal health coverage? Can we “cure” the health care system in America in one fell swoop, or does it make more sense to make changes incrementally? (I covered my opinions about this in last week’s post—obviously I believe that an incremental solution is best.)

Second, issues of quality remain paramount. We can’t afford to consider costs alone, but first and foremost must be able to ensure consistent and predictably high-quality outcomes. Providing consistently high quality health care must be at the top of our priority list.

Third, what is the incremental cost? When I worked at Henry Ford Health System, the number of Ford Motor Company retirees exceeded the number of people actively employed by the company. In many instances, start-up or up-front costs are more expensive, so we must be able to see a cost benefit over period of time, which is why we need to look at least 10 years into the future as far as actuarial costs are concerned. We must also be able to stabilize the system as we make the transition.

Fourth, since we are designing this system to last well into the future, what can we expect 10-15 years from now and beyond? We know that many baby boomers are expected to retire in the near future and that seniors today are aging very differently than our parents did. Today, the average length-of-stay in a long-term care nursing facility is less than 9 months. Yes, seniors today are entering nursing homes later and staying there less time than in the past, which is wonderful. Today, most seniors prefer to “age in place” and retain their independence as long as possible.

Fifth, funding, as opposed to quality, must be variable. I recently returned from a trip to Bogota, Colombia which gave me the opportunity to become familiar with the health and social systems there.

While I admit that Colombia is not perfect and of course cannot condone any human rights violations in the country, I found the social system to be an interesting one. In Bogota, there are 50 private agencies that provide programs of quality for their members that affect all three aspects of daily life: health, education and social. There are three levels of payment for services, based on one’s ability to pay:
1. If an individual can afford to pay, then they pay 100 percent of the cost (full sticker price).
2. If an individual earns four times the poverty level, then they are offered a 40 percent discount.
3. And finally, for those who are at or below the poverty level, the government provides a $400 a month subsidy.
In this way, everyone receives health care, education and social services at a price they can pay.

We must ensure that in whatever system is created, funding is variable but quality is not. Everyone must receive the same level of care regardless of their ability to pay. One life is just as important as the next, no matter what their economic stature may be.

In our facilities in Mexico, we are able to operate clinics for the indigenous communities, most often the poorest of the poor, by utilizing distant monitoring, an innovative and cost-saving approach. Generally, this population lives in rural areas, so distant monitoring allows professionals who are trained in data and evidence-based medicine to monitor these patients remotely.

As a whole, CHRISTUS spent over $286 million last year in community benefit. Every CHRISTUS region must have a plan for caring for the uninsured and underinsured. Our system has always been committed to caring for the poor, and is implementing “medical homes” for the uninsured so they can avoid needing to receive care in our expensive emergency rooms. However, the question is, “Can CHRISTUS Health or any health system sustain this level of charity care into the future?” With declining reimbursement, the answer is no.

Therefore, all the voices of change must come to the health care redesign table in order to ensure that all people receive high-quality health care that is cost-effective and innovative, regardless of their ability to pay.

It’s obvious to me that the plan in place in Massachusetts to require employers to spend 8 percent of their payroll on employee health insurance will not work in Texas. In Massachusetts, less than 10 percent of the population is uninsured. By contrast, over 24 percent of the population of Texas is uninsured. Therefore, those at the table may need to find another system for providing this additional coverage for the large numbers of uninsured and underinsured.

However, in deciding who comes to the table, I trust that those who are chosen to redeem health care are not as important as what is on the table. In the middle of the table should sit a picture of patient surrounded by his/her family so that all the groups can retain their focus on why we’re really here: to provide readily-accessible patient and family-centered care of the highest quality and lowest cost possible. We know it is possible because we already have models to study and incorporate into our redesign!

Wednesday, July 11, 2007

Health Care Reform

Much has been said lately about the state of the health care system in the U.S. Every presidential candidate is talking about it, Michael Moore has made a movie about it, and terms like “single payer health system” and “universal health care” are becoming more and more popular.

I agree that the health care system in the U.S. is incredibly broken. In fact, I believe that the scope of the problem is equal to or may even exceed the problem of world hunger. But just as with world hunger, health care in the U.S. won’t be corrected instantly with one massive program or a “single payer system.” To fix health care in our country, I believe that a series of building blocks must first be put into place that will create a strong foundation on which further changes can occur.

Here’s what I believe those building blocks should be:
First, we need to move as much care as possible out of the hospital setting. Health care provided within an acute care hospital’s four walls is very expensive, so all care that can be moved and rendered in a cheaper setting should be. Here are some examples of how this can be accomplished:
1. Encouraging people who come to the emergency room for care but don’t need urgent care to find a medical home that they can afford. Too often, the poor or uninsured feel they have no other choice than to visit the emergency room for care when they are ill, even if they are not experiencing a medical emergency. They often can expect to receive care they can afford, but generally experience longer wait times and no follow-up care. Too often they don’t receive care soon enough and may have developed complications that would have been avoidable if they had been seen sooner. (CHRISTUS has piloted some innovative programs aimed at helping the uninsured find an affordable medical home. You can read about one of them, our community health worker program called Care Partners, on page 13 of our 2006 annual report.)
2. Strengthening our preventative medicine programs and aligning incentives so people have motivation to use them.
3. Stronger integration with education through avenues such as our school-based health programs, which educate people on disease prevention and appropriate health care utilization while they are teens. This will enable them to become healthier adults and also help educate the next generation of children about the importance of health care.
4. Supporting and developing collaborative programs for low-cost, affordable, suitable housing. If people do not have appropriate social environments and are not educated and at least literate, it will be more difficult for them to pursue preventive health care, let alone be able to follow medical instructions if they are acutely ill upon discharge.
5. Providing basic health insurance for all. This would allow the amount of charitable care to be more equitably shared by all health care providers in the country. It would also help us ensure that the 44 million uninsured people in the U.S. are able to receive the health care they need, particularly the uninsured children. These children are receiving little to no care at all, unless they are covered by a state-sponsored program (like a state-wide Children’s Health Insurance Program).

These are only the basics. After that, we will need to decide how to handle more sophisticated care and elective surgeries like cosmetic and bariatric procedures. Also, we must resolve how we will fund care for the elderly such as independent and assistant living programs. Those issues can be determined after the initial building blocks are put into place.

Also, as the government redesigns the health care system, they need to ensure that one basic tenet is changed: Medicare reimbursement must parallel the most fundamental building blocks in important the redesign. This means that if we really believe that the points I mentioned above will decrease the amount of care received in an acute setting (where the major cost is presently), then we need to make sure ASAP that reimbursement provides an incentive to provide care in a non-acute setting.

One of the reasons the health care system is in such a bad state is because incentives are not aligned to create the changes that need to occur. Acute care (which is often unnecessary) receives the highest reimbursement (funding), while social services, rehab services, home care, and long-term acute care are minimally funded. If we want health care to change, we should be paying as much for a person to go to a health club as we are paying to treat their diabetes (which might be avoidable by making healthy choices like exercising and eating properly).

Once again, I believe the changes must build upon one another. I am constantly reminding our Associates that we will only get where we want to be on our Journey to Excellence in 2016 because we did what was required in 2008 and then built upon that success. The health care system is the same: we fix the foundation and then build upon it.

We at CHRISTUS Health want to come to the health care redesign table and work with the leaders in Washington to design a system that works. We don’t have all the answers, but we do believe we have tried things that have given us some of the answers, and we would love to share our knowledge.

Wednesday, July 4, 2007

Health Care Leadership – My Journey

I thought that as a way of introducing myself, I would spend some time letting you know more about me and how I got where I am today.

As early as I can remember, I always wanted to be a physician. I think that was because I had an aunt who was a director of nursing in a hospital, and my father, who was the manager of a line plant, was responsible for first aid in his job. My father was actually blinded in one eye, and I learned about eye and line burns on the job from him.

Whether those early experiences played any part of my choice to practice medicine or not, I always felt that it would be a profession that I would enjoy and have the skills for, and that it would allow me to feel good about serving others. As a teen, I found myself participating in community projects that served others, and I found great rewards in being a volunteer. I ultimately felt that some of that volunteerism was part of being in the medical profession.

As I grew older and knew more specifically what medicine would require, I made sure that I was academically prepared, and was very focused on my grades in high school and college. My first day of medical school, I went to a lecture and anatomy class and knew I had made the right decision.

I still feel that the best work I’ve ever done in health care has been my clinical work. I have always said—even as I moved into leadership roles—that I am a physician leader and not an administrative leader. I also recognized very early that just as in clinical medicine, you need to function within a strong team to provide excellent health care.

Consequently, I realized that as a physician, I could bring a strong clinical perspective to the table, but also needed to work with other people who could bring strong business skills to the table as well as expertise in other necessary services such as human resources, legal, etc.

I didn’t set out to become a “physician leader”, but I soon realized that I would be able to maintain at least some clinical focus throughout my career, even if I was not actively participating in clinical care. I began that career first as a general surgeon, then worked as a trauma physician in the Emergency Department, and then moved on to Chair of an Emergency Medicine Department. I founded and directed an emergency medicine residency program associated with the ER and developed a poison control center and a hyperbaric medicine program.

As I held my various positions and accepted new leadership roles, I realized that I always needed to be strongest in my clinical expertise. An excellent health care organization has to be driven by what is best for patients and their families, residents of their long term care facilities, etc., and I knew that should be my focus as a physician as well as a leader.

Now I do what I can to stay clinically attuned. I read as much clinical information as I can, and I periodically go to work in one of our three clinics. I have decided that my future clinical work will be predominately done in clinics for poor.

Clearly, as I look back in my career, I began as an informal leader. Even in high school, college and medical school, when I would see things that weren’t working, I would try to get involved with the group of people who could impact or change those things, make them work better. I think that as people see you doing that, they decide that maybe you should be put in a formal leadership role. So I was president of my high school class, Chief Medical Resident in my surgical program, president of the resident’s association in my training program, and then moved on to Chair of The Emergency department, Assistant Medical Director, Senior Vice President for Medical Affairs and then COO and CEO of several smaller groups. It was a progression, but it occurred because I was an informal leader and was always willing to do more than what was expected, more than what was in my job description, because my goal was always to achieve excellence wherever I was. It’s just inherent in my makeup, so that’s what I did. I didn’t start my career with the idea of becoming a CEO; in fact, that would have been furthest from my mind.

I feel strongly that good clinical physicians can be good health care leaders. But they have to be comfortable in understanding that they have to broaden their knowledge base, and they also can’t be overwhelmed with the authority and become arrogant. Many physicians make a mistake and create poor leadership because they know that in order to be a good doctor, you need to be clinically egotistical. What I mean by that is that when patient comes into a physician’s office, that physician must approach the patient with the mindset of, “I’m going to save your life. If I don’t know something, I will seek help. If you die, it will be not because of what I didn’t know, but because there was nothing else that could be done.”

Many physicians get into difficulty in leadership positions when they let that clinical egotism go to their heads and they become arrogant. Arrogance drives dictatorial behavior and the “I” mentality. Health care leadership has to be a consensus and a “we” mentality. Unfortunately, we need more physician leaders, but because of the inability of many physicians to understand the difference between clinical egotism and arrogance, they can’t make the transition.

I am a strong proponent of professional back-talking, which I think is one of the hallmarks of good leadership. This means that leaders need to listen to what they need to hear, not demand what they want to hear. I would hope that discussions with CHRISTUS leaders would be a robust exchange about things that others are hearing that they might agree with, include the sharing of knowledge and the presentation of good rationale behind what they might disagree with. I believe that we as leaders must be open, have strong listening skills and must be prepared to change our positions at times.

The responsibility of leadership and authority are not nearly as important to me as the accountability of leadership, which means that you must produce improvement and positive outcomes to be considered an effective leader.

As I have said before, I am hopeful that my years of experience might be helpful to others who work in health care field or are interested in it. I have had to create a sort of science as far as the art of leadership is concerned, and am frequently asked about what is required for a “journey to excellence” or to create excellent health care leadership. What do you think?