Wednesday, August 29, 2007

CHRISTUS’ Changing Portfolio: 1/3 Acute Care

As I mentioned in previous posts, there are several significant drivers that are rapidly shifting the delivery of health care. Much of the care that was traditionally delivered within hospital walls is now delivered in a more non-invasive and safer way in outpatient settings.

Therefore, it is appropriate to pause and reflect on what will be left in acute care settings and what the hospital of the future will look like. We know that there will be critical services that must be delivered in the inpatient setting because of the severity of illness and the safety factors involved. These—first and foremost—include trauma, which in the 1960s was the leading cause of death in children 7 years old and younger, and has now risen to the leading cause of death in people 51 years old and younger.

It is my prediction that trauma will become the leading cause of death in people 56 years old and younger by 2016. Why? Again, this reflects some other observations which we outlined in previous posts. Many deadly diseases have been eradicated or at least mitigated to some degree, cancer being a prime example. In addition, we have observed a shift in the health level of seniors as well as the baby boomers. And finally, we know that the growth of drug and alcohol addictions world-wide brings with it a large growth in violence and traumatic incidences. Consequently, healthier people are more vulnerable to a traumatic occurrence, and therefore a major percentage of inpatient stays will be related to trauma care, which is very expensive and has a low margin of profitability since it requires a high intensity of supplies and personnel.

A second area of growth in the inpatient setting will be neurosurgery. Many past neurosurgical diagnoses can now be treated with non-invasive interventional technologies such as stents and arterial occlusion devices. It is my belief that a new set of procedures, however, will be developed to treat memory and tremor illnesses such as Alzheimer’s and Parkinson’s disease, and these treatments will require open craniotomies. Any time the skull is invaded, even with minor procedures, inpatient settings are required for post-op monitoring.

A third category of patients who will continue to be treated in inpatient settings will of course be the elderly who need care in their final days. They will most likely succumb to a neurological event, such as a stroke, or a cardiac event, such as a terminal heart attack. However, their stay in the acute setting will be much shorter than in the past, and most of them will very quickly request to be transferred to inpatient hospice settings which may or may not be housed in the acute facility.

Because the cases that we see in the inpatient setting will be different in the future, this will also change the types of physicians and caregivers who will work in these acute settings. From my view, I see the predominant types of physicians that will staff inpatient beds will be predominately limited in the next decade to hospitalists, intensivists, (both pediatric and adult), neonatologists and perinatologists. Obviously, we will still have an array of general obstetricians and gynecologists, but with the advances in these areas, the women’s hospital of the future will much more parallel non-acute settings than they do the more intense acute setting which we described above.

If all of this is true—and we believe our data is proving more and more each day that our vision of 5 years ago is becoming reality—CHRISTUS Health should limit its acute care expansion in a very focused way. In fact, we are doing this by utilizing certain criteria to guide our expansion plans. If we are expanding acute services, they must meet one of the four following criteria:
1. The area must be organically growing, i.e., new populations must be entering the community.
2. The quality of the present services or new services at the facility must be so high that patients who were going to the competitor are demanding that they now be admitted to CHRISTUS facilities, and therefore the present facility needs more space.
3. We will explore the acquisition of facilities where we are called as potential buyers or partners. If they extend our mission, give us a more wide geographical distribution, provide distance from the hurricane-prone Gulf Coast region where many of our facilities are located, or enhance our fiscal stability (so we will have more funds to extend our care for the underserved), we will consider the partnership.
4. We will also consider replacing facilities where we have met our benchmark metrics in all four of our directions to excellence. Obviously, these replacements must be scheduled according to our capital capabilities and, when built, must be designed as hospitals of the future, which will take into consideration all the changes in acute care outlined above. In addition, these hospitals must understand the patient-centricity which the baby boomers will require, the diseases which are present today that will not be present in the future or require inpatient settings, and the importance of providing appropriate environments for end-of-life care which will be demanded—as we as previously discussed—by a large portion of seniors who will require limited acute care but want guaranteed hospice and palliative care with strong pain management.

One inpatient setting that we did not discuss at this time is that required for behavioral services, which will also be changed significantly because of our senior aging process. We will discuss this in detail on a future blog post.

Wednesday, August 22, 2007

CHRISTUS’ Changing Portfolio: 1/3 Non-Acute Care

Historically, CHRISTUS’ portfolio has been predominately focused on acute care, which are services provided in inpatient settings and require a hospital bed. However, because of the factors I outlined in the previous post, we believe this needs to change, and our portfolio must parallel our increased focus on non-acute care.

I believe that one of the most significant enhancements in non-acute care will involve advancements in technology, specifically long-distance monitoring. Through long-distance monitoring, health care providers can now examine nine different parameters of a person’s wellness: blood sugar, weight, blood pressure, urine pH, etc. We believe that number will increase to 26 - 30 parameters so that health care professionals will have a more accurate picture of a person’s health without requiring an office visit. By distance monitoring, patients can retain the best level of care possible without leaving their homes or staying in the most independent living option offered in a senior community.

In fact, distance monitoring is becoming so effective that in our independent living and assisted living campuses, we have applied for and obtained licenses to provide certified home care to their residents. Receiving these home care services and perhaps utilizing visits from a home health nurse enables seniors to live much longer in independent living situations, move into assisted living later, and perhaps never have the need to enter a nursing home.

In my last post, I also addressed the changes in the senior aging process and the large number of baby boomers who are reaching retirement age. In response, we are increasing our focus on palliative and hospice care programs as well as geriatric psychology programs, as we are seeing increased instances of depression in people living to 80 and 90 years old. Also, as people live longer, we are seeing new series of diseases in seniors that we previously would perhaps have only seen in a younger population. As we continue to see these types of diseases (most of which are propagated by environmental conditions, stress, dietary exposure, etc.), we will have to come up with new treatment modalities for older patients who will not opt for highly invasive treatments which have known high mortalities and morbidities.

For instance, I recently heard of an elderly man who developed colon carcinoma in his 80s. When I was in medical school, that was a disease of white males 40 years of age or younger. However, we are staying healthier, living longer, and are now prone to these diseases when we are older. The 80-year-old with colon carcinoma did not, understandably, opt for radical surgery. Instead, he chose minimal, non-invasive surgery, and immediately wanted to be enrolled in our hospice and palliative care program in his region. As a Catholic, faith-based organization, we pride ourselves in not only acute interventions and non-acute programs, but also every sophisticated and innovative palliative and end-of-life care.

Some people say that because boomers are aging and most health care is required later in life, health care are expenses going to rise. However, as discussed earlier, we are choosing not to build hospital beds for the elderly. Instead, we are depending on technology and changing attitudes to move as much care as possible into the most independent setting possible. And as you have heard, we’re so committed to this that we’re changing our entire portfolio.

It is our observation that already, every level of care after an inpatient hospital stay has been changed in some way. For instance, skilled nursing units are now doing what long term care used to do. This will change health care significantly, and we are hoping that this movement from acute (expensive and often invasive) to non-acute (less expensive and often non-invasive), may cause health care costs to decrease instead of increase. As we move toward becoming a more non-acute organization, we will do more of the following: acquiring distance monitoring systems, acquiring Visiting Nurse Associations, developing memory units so we can treat Alzheimer’s more effectively (instances of which will increase). Memory loss is a function of time, and we need more innovative ways to stimulate memory as patients age to be added to our inter-generational Alzheimer’s program in Utah, and our in-house animal programs in all of our senior campuses.

This inter-generational program pairs Alzheimer’s patients with children in daycare for 4-6 hours a day. Animals, including dogs, cats, birds and fish and plants placed into our senior facilities seem to foster companionship and provide enormous energy and stimulation for the residents. I believe that we will have a greater understanding of the mind in the next 10 years (much like our increase in understanding of the heart in the last 25 years). We still may not be able to cure diseases like Alzheimer’s, Parkinson’s, etc., but we may be able to stabilize them and mitigate the most serious side effects.

We recently acquired a senior care facility in the Dallas area and, like our international operations, especially in Mexico, is proving to be a great “learning-laboratory” for us to study and treat innovative models for senior wellness. Historically in the Mexican culture, children took care of parents as they aged. However, we are finding that elderly people in Mexico are considering alternatives so that they do not need to live with children unless they have no alternative, and children are looking for more stimulating environments for their parents. Also, in a recent trip to Japan, I discovered that country has a major issue in providing care for their elderly. They had a goal of funding long-term care for all aging people, and now they have a healthier elderly population who do not want to go to into a nursing home environment, and instead want to be in assisted or independent living facilities.

When we chose to shift our portfolio to focus more heavily on non-acute care to mirror changes in our culture, we signaled a shift in our own culture. Instead of seeing ourselves as a health care delivery system serving people, we must now move to seeing ourselves as an organization that serves people by delivering health care in the most appropriate setting to maintain wellness as long as possible. We now, at CHRISTUS Health, are in the people business.

Wednesday, August 15, 2007

The CHRISTUS Portfolio

As I have mentioned several times, health care is extremely complex. Therefore, it requires much time, effort, and focus on daily operations—particularly in light of the constant changes occurring in the regulatory environment.

However, an additional complexity of health care is that the trends we are seeing today are causing such radical changes in the delivery of care that if we don’t pause now to give sufficient time to envisioning the future, it is a very good possibility that when we reach the future, we will be inadequately prepared.

Consequently, since its inception in 1999, CHRISTUS Health has committed a significant amount of time and effort to monitoring health care trends and planning for the years ahead. After completing our first round of future planning (Futures Task Force I utilizing scenario planning) we recognized that the two major drivers of health care change for both CHRISTUS Health and all of U.S. health care would be:
1) the declining reimbursement under the control of both the federal and state governments, and
2) the rapid introduction of technology that would move a significant amount of health care from an inpatient setting to the non-acute arena. At CHRISTUS, we define non-acute care as “care and services that do not require an inpatient acute care hospital stay” (i.e., outpatient sites, clinics, continuing care retirement communities, long-term care, etc.).

In fact, when we began future planning, we believed—and have subsequently proven—that this introduction of non-invasive technology would be so rapid that it would be disruptive. In fact, it is so disruptive we could not respond rapidly enough to its introduction and were burdened with the question, “Should we purchase the first generation of the technology, or wait to purchase the second generation?” Technology is changing so rapidly that with limited financial resources, this question needs constantly to be asked, and then, as objectively as possible, be answered using data as rationale.

A living example of this dilemma which occurred in the last 10 years, was the introduction of lithotripsy. If you are as old as I am, you can recall that this technology was first introduced by requiring that patients be immersed in a water bath. It was clear to me as a practicing physician that this technology would not be long-lived, particularly because
1) If patients coded in the tub, how could they be revived without significant movement?
2) It would eliminate a large number of obese patients who were unable to be placed in the tank.
3) And it would eliminate a large number of patients who were afraid of water.

However, I was bombarded by requests from Urologists to purchase this technology as quickly as possible. Those of us who owned the first generation of lithotripsy devices soon realized when the second generation of dry lithotripsy was developed in response to all of the concerns outlined above, that we had indeed wasted $1.5 million and had to find another use for the small swimming pool we now owned.

With all of this learning, CHRISTUS Health has utilized these drivers to recognize that acute care will be significantly changing in the future, and that a much greater emphasis needs to be placed on the non-acute product lines. In addition, CHRISTUS is somewhat unique because of our strong international presence, predominately in Mexico.

Because of this, we have begun the transformation of our portfolio to one-third acute, one-third non-acute, and one-third international. I will cover each of these thirds in more detail in future blogs.

However, today, it would be appropriate to discuss two more drivers of this transformation, those being:
1) the senior aging process and
2) the large number of baby boomers who are reaching 65 years of age.

With regard to the former, it has been our observation while studying the seniors on our senior campuses (independent living, assisted living and long-term care), that these people—often with average ages between 85 and 90—are not aging like our parents. They are staying healthy for a prolonged period of time, have a strong desire to stay in the most independent living situation possible, and in their final weeks, are often facing an acute illness such as a heart attack or stroke, which cause them to request hospice care for a shorter period of time.

This is verified by our data that indicates that people stayed approximately three-and-a-half years in our long-term care facilities in 1999. Now, they spend less than 9 months on average there, instead spending most of their time in the independent living or assisted living locations.

It is important to note, also, the findings of an ongoing study in the United States of over 4,000 people who are over 100 years of age. These people have no common characteristics related to avoiding common health risks, i.e., obesity, smoking, alcoholism, etc. This population includes all of these health-risk factors. Instead, surprisingly, the four things they have in common are:
1) They are optimistic people; they always see the glass as half full.
2) They have learned to accept loss and move on. Most of these people have buried their spouses and all of their children.
3) They stay on a relatively routine schedule each day, meaning they get up at pretty much the same time each morning, eat their meals at the same time, and go to bed at the same time.
4) They all have an avocation. It may be as simple as meeting at Starbucks or the local diner for their morning coffee, or as complex as a daily golf round or a bridge session.

For me, this data indicates that if you live beyond 65 to 70 with a chronic illness, you have reached a stable relationship with that illness and will probably not die early because of it, or one of its major complications. For example, we do not find a large number diabetics in their 70s or 80s who develop gangrene or blindness, because they have learned to manage their disease. Consequently, when their final demise occurs, it is rather related to a short-lived acute episode as mentioned above. Therefore, this population of people—rather than requiring extensive inpatient stays and therefore new hospital beds—will want their care in non-acute settings accompanied with outpatient hospice support.

The baby boomers, on the other hand, are a population of people who want their care as rapidly as possible, as affordable as possible and with the highest quality possible. They are also being burdened with increasingly larger co-payments and therefore are much more focused on where, when and from whom they are going to get their care.

By doing a survey of this population, we have learned that they will much prefer to have their care in a patient-centered urgent center, mini-clinic, or other outpatient facility. They will only opt for inpatient beds which when absolutely necessary. And if it is necessary, they will want a room that is far different than our present hospital rooms. They will want them to be large enough to accommodate families at all times—much like we have in Mexico—and they will want full access to all the internet technologies so their communications, either from themselves or from their family members, will never be disrupted.

So our transformation has been driven by a clear understanding of the present complexities, the future vision and the major drivers of health care in the future. Transformation, we believe, is required if this future is going parallel with what patients and their families will desire and demand in the next 10 years.

Wednesday, August 8, 2007

Medical Tourism: The CHRISTUS Story

Because CHRISTUS is a Catholic, faith-based health care system, some of our potential strategies are driven by a “call”, meaning that other health care systems ask us whether we might be interested in partnering with them. Such was the case in early 2000, when we received a call from the Muguerza health system in Mexico. Because of the growing Hispanic population in the U.S., the increasing need for nurses from nursing schools in Mexico and the proximity of several of our markets to the U.S./Mexico border, we felt there were compelling reasons to enter into sincere conversations with the owners of the Muguerza hospitals to explore this opportunity.

As a result of our due diligence, which clearly demonstrated significantly high quality of both clinical and service delivery in their two facilities in Mexico, we consummated the partnership in April of 2001 and created what has now become the rapidly growing seven-hospital CHRISTUS Muguerza health system in Mexico, which also has a quickly expanding ambulatory component.

Our Journey to Excellence was rapidly embraced by the leaders in Mexico, who shared our strong commitment to prove the excellence in their health system by being transparent in well-defined metrics. That commitment to excellence was not only proven by their data, but was so significant that it generated a CHRISTUS Muguerza brand that is so strong that other facility leaders are now wanting to join our ranks.

As we reflected on CHRISTUS Muguerza’s high quality (as one example, we are the leading cardiac care center in all of South America), it became clear to us that we should not limit this quality to just people in Mexico, but should open our doors to people in other countries who were on long waiting lists for elective surgery or who did not have the financial wherewithal to have their procedures done at the costs that were being dictated in their home locations.

Consequently, we knew that we needed to develop a well-thought out and excellent medical travel program. This was also substantiated by our data, which indicates that many Americans from border states are already coming to our facilities in Mexico, and that the 4,000 Medicare-eligible patients are often paying for their care in our facilities. Why? Again, because the CHRISTUS brand is strong, denotes our Journey to Excellence, and produces measurable outcomes in both quality and service delivery.

In fact, we’ve received quite a bit of attention in the news media lately because of the high quality and convenient services provided at our CHRISTUS Muguerza facilities. One of those stories ran in the Dallas Morning News recently, and you can read it here. TV news coverage also ran recently on one of our CHRISTUS Muguerza hospitals, Alta Especialidad. You can view a TV broadcast about the hospital and our medical travel program via the website of a news station in San Antonio, Texas here.

Obviously, we are competing against medical travel programs in India and Asia that have been established longer, but we feel strongly that our services have an edge because of the close proximity of many of our facilities to the U.S./Mexico border, our Associates’ fluency in English and other languages, and our ability to provide appropriate recovery locations such as upscale hotels and retreat centers.

In addition, a medical travel program allows for more collaboration both ways across the border. For instance, if we have a pediatric patient at a CHRISTUS Muguerza facility in Monterrey, Mexico who needs specialty care, we have the ability to refer them to our CHRISTUS Santa Rosa Children’s Hospital in San Antonio, Texas.

I should also point out that although many other medical travel programs are driven by financial gain, our desire to create a medical tourism program was driven by our high quality and interest in community value. Obviously we are expecting to see financial benefits from this program, but our margins will be of great use as we continue to provide charity benefits to the communities we serve in the U.S. and in Mexico. We are the number one Catholic provider of community benefit, and see this function as central to our mission.

In fact, the CHRISTUS Muguerza system has opened five clinics so far in mainly rural areas to provide health care and other services to residents who would otherwise have little access to it. These clinics were opened in collaboration with local government leaders and health care providers, and are located in desperately poor and underserved areas. They provide high-quality medical care to those whose health is at risk due to social, cultural and economic conditions, and charge very small fees for their services. The services offered at the clinics varies by location, but includes basic health care services such as x-rays, ultrasounds, physical therapy, laboratory services, physician exams and chronic disease management – in addition to counseling and activities for older residents and mothers, and various community education programs.

Our answer to the growing popularity of medical tourism is to continue to leverage the expertise of our existing international facilities. I am very proud of all of our Associates, including those at our CHRISTUS Muguerza facilities throughout Mexico who provide excellent, high-quality care to their patients every day—patients who entrust their lives to us! What an awesome responsibility we, in health care, have!

Wednesday, August 1, 2007

The Importance of Transparency

Because people come into our facilities and programs each day, putting their health—and often their lives—in our hands, they deserve to know as much as possible about us. They want to receive health care services that are excellent and will result in the best outcome at the most affordable price.

We at CHRISTUS Health are committed to provide this information to our patients, residents and their families so they can make informed decisions about us. We are committed to total transparency in all we do.

This transparency ensures that our patients, their families and our Associates and physicians can hold each other accountable to the high standards of compassion and excellence that we have set for ourselves.

If we expect our patients to be loyal to us and trust us, we must return to them our measured outcomes so they are assured that we are committed to our Journey to Excellence and to carrying out the healing ministry of Jesus Christ.

Because of this commitment, CHRISTUS Health reports the following on its website:

We began posting our financial performance on our website in 2000. Since we are not a “public company”, we aren’t required to report this information online. However, because of our strong feelings about transparency and the increased scrutiny of public corporations’ financial health following the Enron scandal and passing of the Sarbanes-Oxley Act, the public reporting of this data has become even more important.

This section includes our audited financial numbers for the previous fiscal year. It begins with an overall financial summary and also includes downloadable files which report on our financial operating performance, balance sheet and cash flow statement for the previous fiscal year.

Community Benefit (our financial commitment to charity care)
We began reporting this in 2002, long before it was a hot-button issue. This section of our website includes our Community Benefit Annual Report, which reports the amounts we spent on charity care, community services, government-sponsored programs and total community benefit in the previous fiscal year. This section also includes information on our CHRISTUS Fund and its grant recipients as well as information on CHRISTUS’ dedication to community health. Recently, we have added region-specific community benefit information to the site.

This information debuted on our website in October of 2006, and is be updated quarterly. An FAQ section explains quality and how and why we measure it, and the site includes credentials and accreditation information, reports our performance on measures that we are required to provide to the Centers for Medicare and Medicaid Services (CMS) by system and facility, an explanation of each measure/treatment and why it is important and related information on prevention of disease.

Patient Satisfaction
This information also debuted on our website in October of 2006, and is also updated quarterly. Again, an FAQ section explains how we measure patient satisfaction and how we interpret it. We report our overall score and service measures (prompt care, concern for special needs, communication and courtesy and compassion) by system and facility. Also, we explain these measures in more depth, paying special attention to our service measures, which we feel define us as a Catholic, faith-based health system.

This section debuted earlier this year. It includes links to the insurance carriers we work with, lists our pricing discount policies and displays estimated hospital charges for our most common procedures system-wide.

What other information about CHRISTUS would you like to see us post on our website?