New Year's Wishes

As we look forward to New Year’s Eve and the dawning of another new year, many of us are probably contemplating our New Year’s resolutions. We will start the year freshly focused on the habits we would like to improve or on learning new skills in order to continually shape ourselves into the men and women we would like to become.

It strikes me once again that our pursuit of excellence in our CHRISTUS facilities and business groups is much the same as keeping a New Year’s resolution. Resolutions are kept not by making one initial decision, but by making many decisions in the days to come.

For instance, I bet that many of us will resolve this year to eat healthier and lose some weight. It is clear, though, that we don’t lose weight just by deciding on Jan. 1 that we will. No, we lose weight by increasing our physical activity every single day and by eating healthier foods at each and every snack and mealtime. It is the small, daily decisions that help us to reach our goals and fulfill our resolutions.

In the same way, it is the choices we make each and every day that help CHRISTUS achieve excellence. It is taking a few extra minutes to ensure a patient truly understands his or her treatment. It is double-checking our work to ensure that we are administering the correct dose or submitting correct facts and figures each and every time. It is taking a moment to speak to a resident or coworker who may need to hear a kind word.

Yes, excellence—just as our New Year’s resolutions—is achieved in small, incremental victories every day, and is therefore within reach for each and every one of us.

Best wishes to you and your families for a peaceful and happy new year. May God continue to bless our ministry.

A Christmas Message

The lighted trees and glittering decorations assure one that the holiday season has arrived. The traditional Christmas shopping begins in preparation for the much-awaited gift-giving among family and friends. As we ponder some of the greatest gifts we have been given, it is probably the reality that the image of a watch, piece of jewelry, or even a bottle of cologne or sweater could quickly pop into our minds. However, after more reflection, it could be possible that for all of us – as members of the CHRISTUS family – we are reminded of the gift we received with the birth of Jesus centuries ago. Because of this, today we have not only the privilege but the awesome responsibility of carrying out His healing ministry in our acute, non-acute and international ministries – our Mission.

Speaking of gifts, I was recently given a coin by Fernando Ferraro, the first CEO of CHRISTUS Muguerza, who now works part-time with Peter Maddox in exploring international business development opportunities. This special coin reminded Fernando of the original call of Bishop Dubuis and the value of mission as he writes in the coin’s story, which follows:

The Value of a Mission

In a community high in the mountain called Pena Nevada in northern Mexico, a poor farmer named Homero, my friend, came to me and placed a coin in my hand. He asked, "How much is this coin worth?"

I looked at it and read the script that was written in English on the top of the coin’s face.

“No cash value.”

Then, I turned the coin over and saw a funny clown face stamped on the other side.

Immediately, I realized that this coin was a token coin that came from an amusement park or a fair playground and it is used to pay for children’s rides and games. I answered Homero, saying that this coin did not have any monetary value.

After answering him, he smiled and said, "I give you this coin as a present." I smiled back and thanked him for this gift. Later on, I learned the great spiritual value of this coin.

Many thoughts came to mind as I was flipping the coin, scrutinizing its two faces.

I realized that when you have a mission in life or a path to accomplish, this is a duty, and the duty has come from our faith or our conscience. This mission of duty has "no cash value," which means that these actions are fulfilling a spiritual goal. These goals do not give back any monetary rewards during our lives and that it’s a duty that makes us, by choice, fulfill and accomplish it.

In my opinion, missions in CHRISTUS Health can be paid with these illustrative coins and they should always be, figuratively speaking, in our pockets or wallets to remind us of our commitment to this mission and our spiritual goals.

I recognized another message on the other side of the coin with the funny clown face. This image told me that we have to see our mission with a child’s mind, without discrimination of any kind, with a joyful spirit, having fun with what we do even if it means making a choice or sacrifice, always looking for the feeling of joy as the result of serving. We have to see our mission from a child’s point of view and child’s heart.

Rabindranath Tagore’s poem summarizes the essence of our mission.

"I slept and dreamt that life was joy, I awoke and saw that life was service, I acted and behold, service was joy."

God has created everything, including our mission, and in making our mission joyful, we bless all creation and ourselves as well; that is why we [serve], because we have been blessed already.

Isn't a mission that compels us to perform worthwhile service perhaps the greatest gift we can receive during this holiday season? As we journey toward CHRISTUS’ 11th birthday on Feb. 1, 2010, may we all give thanks for a mission that calls us to serve; patients, consumers and residents who trust us with their health and often their very lives and the blessing of extending compassionate care to our neighbors in their time of need.

On behalf of the senior team, I wish for all of you and your families and loved ones a joyous Christmas season and for the new year of 2010 to be filled with much peace and happiness.

Health care reform at a critical juncture

Discussions on health care reform continue in the Senate, which may be on target to meet its self-imposed deadline of passing a bill by Christmas. Of course this will not be the last word—the Senate bill and House bills must be reconciled before a final bill reaches the President’s desk, so a definite picture of a final bill is still a ways off.

However, a recent Washington Post-ABC News poll found that Americans are cooling to health care reform as the debate continues to drag on. The poll found that just 37 percent of those polled believed that the quality of their care would be better under a new system constructed by reform, while 50 percent see it as better under the current set up.

I find this dichotomy interesting. I know without a doubt that miracle moments occur in our U.S. health care facilities every day. However, it is widely reported that the American health care system falls behind the health systems in other developed nations. The Commonwealth Fund’s 2007 report, Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care, reported that the U.S. health care system ranked “last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives” when compared with five other nations (Australia, Canada, Germany, New Zealand and the United Kingdom ).

However, the attempt to reform the health care delivery system in the U.S. can never be a discussion solely about costs or benefits or insurance plans. Those things are all important discussions to have, but they are not the most critical. This is why I have said from the beginning that those in our country who are having discussions about the shape and direction of reform should have them around a table with a picture of a patient and his or her family in the center. It is imperative that we remember that health care reform—just like health care delivery—is about people and their lives.

Ezra Klein, a blogger for The Washington Post, reminds us that we may want to start referring to these bills a “150,000-plus-life health care plan,” as he calculates that, based on the Institute of Medicine and Urban Institute’s data, this is the number of lives lost due to lack of insurance over 10 years.

The bills under consideration by Congress may not be perfect, and may have to be re-examined in 8 to 10 years. However, the process of moving toward accessible care for all Americans is an important one, which is why CHRISTUS continues to do our best to stay involved.

CHRISTUS’ Journey to Excellence and experience providing care for all those who need it, regardless of their ability to pay, positions us well to understand the far-reaching impacts of reform. CHRISTUS operates in some of the states with the highest uninsured numbers in the country, and has been forced to create more effective ways to provide care within the structures that exist in the very different states and even countries where we operate, aiming to become the low cost, high quality provider in each of our markets.

So we continue to work to tell our story. Because it is CHRISTUS Health’s mission to extend the healing ministry of Jesus Christ, we are called to support the life and dignity of every person from conception to natural death. Consequently, we are committed to bringing swift fundamental change to the health care system of the United States.

In regard to the Senate legislation, we are supportive of the principles articulated by the Catholic Health Association and broader reform measures articulated by the Bishop’s Conference in their document entitled, A Framework for Comprehensive Health Care Reform. In addition to these, we support the following principles, which we believe are embraced by the Senate bill:

• Oversight: Health providers must be accountable for demonstrating that the care they provide is high quality and cost-effective. We believe that reimbursement systems should reward quality, not quantity, of care.
• Standardization and Collaboration: CHRISTUS supports efforts to reduce barriers among all health care providers so that standardization exists in the provision of care and to ensure that care is better coordinated among providers.
• Workforce Initiatives: An expansion of health coverage must address the need for a workforce to meet the primary care needs of a population that previously could or did not access preventive care.
• Future Planning: A bill crafted now may fit the country’s needs for approximately the next several years, but given the advances we expect to see in medicine, science and technology, it may not be sufficient for the future. . Therefore we must anticipate revisiting health care reform in the future. Your legislation should include language which easily facilitates and anticipates needed changes and adaptations.
• Cost and Coverage: CHRISTUS agrees with Congress’ call on employers, individuals, unions, suppliers, insurers and other providers to do their part to contribute to health reform so that premium subsidies will put coverage within reach of those who could not otherwise afford it. We also support current advocacy efforts to provide additional subsidies to those with incomes from 133 to 150 percent of the federal poverty level, as well as to increase the number of people with health care coverage and/or scale back the proposed reductions in Medicare and Medicaid disproportionate share hospital funding (DSH).

Let there be no uncertainty – CHRISTUS supports health reform as the ultimate issue for promoting the health and well-being of our nation and those that reside here. It is morally and ethically right, and it is good for our economy and national security.

Positive health care news

Since most health news these days seems to carry the urgency or complexity of discussions on reform, disappointing statistics or lists of behaviors to avoid, it’s nice to hear some good news for a change! Melinda Beck of the Wall Street Journal recently published a list of 20 health care advances to be thankful for this season. They include:

• Life expectancy in the U.S. reached an all-time high of 77.9 years in 2007, the latest year for which statistics are available, continuing a long upward trend. (That's 75.3 years for men and 80.4 years for women.)
• Three out of 10 U.S. schoolchildren aged 5 to 17 in 2007 did not miss a single day of school because of illness or injury during the preceding 12 months.
• The proportion of undernourished children world-wide under five years of age declined to 20% in 2005 from 27% in 1990.

These advances will undoubtedly continue to reduce the need for acute, inpatient health care resources, supporting CHRISTUS’ move to expand our portfolio to include one-third non-acute care. Most importantly, though, Melinda’s article highlighted the fact that life from a wellness perspective is getting measurably better for many people here and abroad.

A Reaffirmation of the Importance of the CHRISTUS Health Enterprise Risk Management Program

Approximately two years ago, we evolved our traditional risk management into a strong, system-wide enterprise risk management program. We recognized that in our economically complex health care environment, risk was moving far beyond medical liabilities. The importance of this transition is highlighted in an article featured in the October 2009 edition of Risk Management magazine.

Entitled “Eyes Wide Open,” this article explains clearly how by examining macro trends, companies can identify emerging risks. Identical to our goal for establishing a strong enterprise risk management program, the author indicates that,

. . .Risk taking should be understood and risks should be appropriately managed. Having the ability to recognize new risks as they emerge has become increasingly important in today’s evolving economic, social and political landscape. By examining macro trends, organizations can help identify many emerging risks early on, which will allow for more proactive risk management.

By utilizing a survey of potential risk areas completed by an array of CHRISTUS leaders from our system departments, regions and business units, 18 critical risk areas were identified and prioritized utilizing the four major drivers of risk outlined in the final page of the article, which include:
• Impact: What effect will the event or scenario have on the company?
• Velocity: How quickly will the event or scenario impact the company?
• Materiality: Can the effect of the event or scenario be overcome with existing resources, or would it require a
significant change in the business model, skill set and mind-set?
• Reputation: What is the possibility of adverse publicity or damage to the company’s reputation?

Having the enterprise risk management program in place and presently working on the six highest ranking risk areas identifies CHRISTUS Health as a leader in this area so crucial to our future success.

A Thanksgiving Reflection

At this time of year, it is so important for each member of the CHRISTUS Family to pause and review all for which we should be thankful, both in our personal and professional lives. We are truly blessed in so many ways as we have been called to serve in this sacred ministry.

As we continue our Journey to Excellence, guided not only by our three strategic drivers, five strategic directions and eight strategic enablers, but also by any new directions that will be mandated by health care reform, it is clear we will need to continue to embrace new skills and competencies in our work.

Embracing change will be essential to supporting our continuing portfolio transitions to become one-third acute care in the U.S., one-third non-acute care in the U.S. and one-third international. New energies will be required to continuing to reach our goal of becoming one of the highest quality and low cost health care providers in the world. In light of our continuing need to change and grow, I thought it would be appropriate to share the “Reflection on Autumn Days” below. On behalf of the entire Senior Team, I extend our sincerest of thanks to every CHRISTUS Healer for all they do to serve in our ministry and to extend their hands to care for the multitude of sick and infirm.

Reflection on Autumn Days
By Joyce Rupp

A new season is moving in. We can sense its presence in the coolness of the breeze and the quick gusts of wind that wrap themselves around browning lawns and fading forest leaves. This time of transition belongs to more than just the earth. Inside of us there are also quiet changes sending us their signals to let go.

Trees of radiant green say goodbye to another year’s growth. Their leaves break away, sailing to the ground. They tell us that in the deepest part of who we are, there is always a call to continue our transformation process.

Across the land truckloads of harvested fruits, vegetables, and grains make their way to market. Gardens and fields give of their gifts. Growers fill their baskets and wagons. Sometimes it is only when produce is gathered or grain is caught into our wagons that the harvest is seen in its bounty. We, too, are meant to count our blessings even when the reaping at first looks sparse and lean.

Frost shakes the warmth out of autumn weather and shapes itself into the first hues of winter. We begrudgingly see the signs of future cold and emptiness, knowing full well that our hearts are not immune to this seasonal direction.

We wake up to misty mornings full of dampness, covered by clouds that hang low. Wetness rests on what remains of summer’s beauty and fog tried to hide the road before us. We walk once more into the mystery part of life, recognizing that the inner journey has its clouded, foggy pathways.

Color enriches autumn days with the last laughs of lovely marigolds and the visual flavors of rusted oaks and yellowed maples. A blessing called beauty kisses the sadness in their dying and makes of the ache a tender thing. When our own pain is great we look for beauty and know its soothing respite.

Geese are going south, as are all flocks of birds whose hearts lean toward the sun. They are in tune with the inside timing. We need that same gift of inner sensing so that we can be aware of our leaning toward the divine and follow what is being called forth in the depths of ourselves.

Beyond us, in distant places, there are other seasons of the earth and of the spirit. Wars with weapons are mixed with struggles of greed and power. Little children yearn to be fed and old people dream of days when there was peace enough for all.

We are autumn people. We are always called to be in the process of growing and changing. May our minds and hearts be open to this inner season which is a part of us. May we trust you, Autumn God, who calls us to grow. May we find hope as we enter willingly into the dying that is needed for our transformation.

Leadership at this Moment in Time: How to Lead an Organization through a Perfect Storm

I recently presented the keynote Donald Dunn Memorial lecture at the 31st Annual Iowa Healthcare Executive Symposium, which I want to share with you. My presentation, "Leadership at this Moment in Time: How to Lead an Organization through a Perfect Storm," was about the perfect storm health care in the U.S. has found itself in and how leaders can best react and respond to all the changes in our industry and on the horizon. It covers many subjects I have discussed previously on my blog about leadership and the current state of the health care industry.

Leadership Through the Perfect Storm

View more presentations from CHRISTUS Health.

I think it is important to close this presentation with a big thank you to each CHRISTUS Associate for the part they play in making this story our reality at this moment in time on our Journey to Excellence! These CHRISTUS Healers continue to make me extremely proud to be on their team as I continue to reflect on the awesome responsibility of leadership in this sacred ministry.

CHRISTUS Health Supports National Health Reform Efforts

In the Gospel of John, chapter 10 verse 10, when Jesus is describing himself as the good shepherd, he speaks about how he protects his sheep (which we interpret to be the people he has created and loves). He said, “I came so that they might have life and have it more abundantly.”

It is no secret that the 46 million uninsured Americans live sicker lives and die younger than those with insurance coverage. An estimated 18,000 - 22,000 Americans die each year because they don't have health coverage, according to studies conducted by the Institute of Medicine and the Urban Institute. This is far from an abundant life, and we are concerned that the number of uninsured Americans is rising, as we see a rise in the amount of charity care we’ve provided over the last year.

We will of course always provide community benefit and charity care, as it is CHRISTUS’ mission to extend the healing ministry of Jesus Christ. But we know that this is not the best or most cost-effective way for Americans to receive care. We want to ensure that our community members have access to high-quality care in medical homes that can better manage ongoing conditions and chronic disease than our Emergency Departments can.

This is why CHRISTUS Health supports the health reform efforts currently taking place in Congress. We agree with Sr. Carol Keehan, president and CEO of the Catholic Health Association, who after the U.S. House of Representatives passed the Affordable Health Care for America Act (H.R. 3962), said that, “There is no perfect bill, nor will there be, but the leaders in the House of Representatives have crafted a good health reform bill that gets this nation a step closer to the health care system the American people deserve and can be proud of.”

We cannot let the perfect be the enemy of the good, and while there is not a perfect reform bill, the time to act is now. This is why we have been blogging about health reform and visiting legislators, regulators, thought leaders and advocates to tell the CHRISTUS story. We have been honest with them about the concessions we are willing to make and the additional approaches we would like to see in a final bill.

One of those is medical liability reform (often called “tort reform”). In 2003, the Texas legislature passed sweeping medical liability reform legislation. For CHRISTUS Health, the impact was immediate and enormous. In 2004, the CHRISTUS system had budgeted $14.5 million to cover liability insurance. Instead, we were able to reduce that annual charge by nearly $10 million. Since then, we continue to see equally impressive savings, allowing us to reduce charges to our health care centers for their self-insured and excess medical malpractice coverage. Our communities benefit because we are able to reinvest a good portion of those savings in safety and risk reduction programs.

Medical liability reform on a national scale would reduce medical malpractice insurance fees and also decrease overuse of many lab and radiology testing services while still providing patients who are injured by negligent medical care with the right to full recovery for their economic damages. Medical liability reform that does not supersede those already enacted by some states should be included in Federal health reform efforts.

So when a member of the staff of Texas Governor Rick Perry called to discuss our tort reform experience, I gladly talked with him about the savings we have seen and how we have reinvested them in programs to keep our patients safer during their stays in our facilities.

Many of you have probably seen the editorial in The Washington Post written by Gov. Perry and Newt Gingrich, former Speaker of the House of Representatives, expressing their views on national health reform and their position that states should be allowed to lead the way. They point to CHRISTUS’ savings from medical liability reform as a statewide approach to controlling health care costs.

It is true that CHRISTUS has benefitted from the medical liability reforms passed by the Texas Legislature, that we appreciate the mention in this editorial are always happy to work with Gov. Perry. However, I want to make clear that we do not share the views on national health reform that were expressed in the editorial.

Instead, we believe that health reform on a national scale that meets our Putting Care Within Reach® goals should be passed as soon as possible. While we know that this reform will not be a perfect, immediate, or eternal fix, we believe the time is now to take these large and important steps forward.

Leading CHRISTUS in the New Economic Environment, Part 2

In last week’s post, I discussed my interview with two representatives from IBM who asked to hear my thoughts for their 2010 Global CEO study entitled, “Leading in the New Economic Environment.” Many of their questions dealt with change and the external forces that CHRISTUS has been forced to respond to in order to remain successful and continue fulfilling our mission of extending the healing ministry of Jesus Christ.

But they also wanted to know about the internal systems and resources that must be in place for us to navigate the changing waters of the new economic environment.

They wanted to know which characteristics in our leaders are uniquely important in the health care industry. I named
• Compassion first, because decisions must be made with patients and their families at the forefront;
• Excellence, since our patients come into our facilities and turn their lives over to us every day, therefore we believe that excellence is a necessity, not a luxury and
• Optimism.

In fact, I believe that leadership and holding our leaders accountable will be some of the most crucial capabilities CHRISTUS will need in the next five years to execute our strategic plans and meet future opportunities successfully, and these leaders will need a whole new set of competencies that we didn’t need 10 - 15 years ago.

As an example, because of the recent instability in worldwide financial markets, I have had to become increasingly savvy in the treasury function of our operations. Our bond financers now expect us to basically perform as a for-profit, and in order to refinance our bonds, I am asked to talk to investors. They want to know that I have the knowledge to make things go well, and are no longer content with hearing solely from our CFO.

I say repeatedly that where we are successful in CHRISTUS, it is because we have the right leaders and teams in the right place, and where we are not successful, it is because we do not have the right leaders and teams in place. It has little to do with our assets, the age of our buildings, or anything else. Success starts with leadership, and our experiences in the economic climate of the last 12 months has taught us that we must continue to develop leaders with the capacity to change. (Earlier this year, I blogged on what leaders must do/change in challenging economic times. If you’re interested in reading that post, it’s located here.)

Our experience over the last year has also taught us that in the future, we will have to look at new and innovative ways to communicate with both internal and external stakeholders. Times of instability remind us once again that if there is a communication gap, it will get filled. (And usually it is filled with rumors fueled by fear.) We know that CHRISTUS is well positioned to meet future challenges because of our extensive future and strategic planning, but we have less time to execute these plans because of the health reform that now seems imminent in the U.S.

We have also learned that we will need to continue to enhance our intense focus on metrics. Without metrics, you can’t hold people accountable. We must continue to focus on a few critical success metrics and communicate upfront what’s expected of people if we are to attain them. In addition, these metrics must interconnect. Our Journey to Excellence sets out a path for us to achieve high quality in our 4 directions (clinical quality, service delivery, business literacy and community value), but we’ve learned that we must improve in all those areas in a parallel fashion, as they don’t operate in a vacuum, but together form one complete picture. And we know that this is possible, as we have just finished our best financial quarter in 11 years. We will continue to rely on our balanced scorecard and Strategic Portfolio Analysis (SPA) algorithm to help us track and report on these metrics.

Leading CHRISTUS in the New Economic Environment, Part 1

Early this week, I met with two representatives from IBM who asked to hear my thoughts for their 2010 Global CEO study entitled, “Leading in the New Economic Environment.” IBM publishes a CEO report every two years, and interviews 1,200 CEOs across the world regarding how they will lead into the future. This is useful for IBM, as it also provides them with a chance to survey their audience about the directions they will be headed, since IBM has evolved over time from a technology-driven business to a focus on business process and “helping businesses solve the big problems of the day.”

One of the first questions they asked was, “What are the three most important external forces that will impact your organization over the next three years?” I was able to choose from a list they provided, and identified:
1. Regulatory concerns. The change brought to our industry by health care reform will be revolutionary. I still think this is a great time to be in health care, though. I often say that the “good old days” really weren’t that good. We’re able to treat so many more diseases because of advances in medicine and technology than when I was a med student. Granted, these days may not be easier, but they are much more rewarding, and require that we truly must figure out how to be the high quality, low-cost providers in our communities. Ten years ago, you could sleep in your office and make money because Medicare reimbursement was so high. Today, though, only the high quality/low cost providers will be able to prove their value to consumers and survive.
2. Technological factors. CHRISTUS has a commitment to incorporate small technologies (technology that is owned by most people) into every day care. We know that it is possible for diabetics to take a blood sugar reading by feeding a blood sample into their cell phone, which can read it and then send the results to their physician. We also know that tools are being developed for and in use at our Senior campuses like toilet seats that send messages to remote caregivers if the toilet has not been sat on or shoes that send similar messages if they have not been put on. These signs let us know that a Senior in our care has not gotten out of bed, and may need help. All of these tools help us as we move from “health care” to “health.”
3. Globalization. Because of the regulatory environment in Mexico, we operate there as a for-profit and reinvest our profits in our clinics for the poor in rural areas of Mexico. We are now the second largest for-profit health system in Mexico, and are exploring opportunities to expand into Panama and Peru. I really do believe that 10 to 15 percent of the health care solution in the U.S. will be provided by medical travel to Mexico. And we expect the current number of 1 million American expats in Mexico to grow because of our recent recession that undoubtedly affected many retirement funds.

We have worked hard over our history to manage change, which has positioned us well to meet the challenges and opportunities of the future. We have expanded into Mexico; systematized many key functions like our supply chain and home care activities; made future planning a key focus of our organization and are currently reorganizing our portfolio from an emphasis on acute care to 1/3 acute care, 1/3 non-acute care and 1/3 international facilities.

Innovation is a key part of our future planning strategy. This is why we have created and sponsored two Futures Task Forces in our 10-year history as CHRISTUS, and why we founded the CHRISTUS Innovations Institute. We have partnered to systematize our supply chain, extend care to the poor in Mexico and provide psychiatric services at Our Daily Bread in Galveston, Texas, which provides support services to homeless men, women and children.

The folks from IBM who visited with me this week had many more questions about CHRISTUS and our future--too many to fit into one blog post. Therefore, I plan to revisit some of their additional questions in next week’s post as well.

The Cost of Care, Part 5 of 5

The fifth and final section of the Dallas Morning News’ series called “The Cost of Care” featured the approach of Scott & White Healthcare (sometimes called “The Mayo of Texas”) to collaboration instead of competition, examined why primary care physicians may be choosing to move to other models of care delivery and what the U.S. can learn from other countries’ health systems. You can access the series here.

The first article in the final section of the series reports on Dr. Bill Walton’s final day in his 31-year-old popular family practice in Dallas. Walton is moving to Temple, Texas to join Scott & White as a salaried physician because of the pressures and costs of running his solo practice, also known as the “business of medicine.”

The Newsexamines why primary care doctors are “becoming an endangered species.” I have addressed this problem on my blog numerous times. If you are interested in some of my thoughts, you can hear them here. It is clear that the trials and tribulations of primary care doctors must be addressed if we are to provide adequate care to Americans, and especially if larger numbers of them will have insurance coverage in the near future.

The second article provides an in-depth look at the strengths and weaknesses of Scott & White, which is an accountable care organization (ACO) that uses salaried doctors and a team approach to deliver high quality care at a low cost. The company controls costs by managing all aspects of medical care, including health insurance, outpatient clinics and hospice centers. ACOs received quite a bit of attention this summer, as some health care reform proponents suggested them as a way to reward physicians for the quality of care they provide, instead of the amount of procedures they perform. We supported including a Super MEDPAC or Super IMAC if the organization had the power to evaluate ACO and cost-saving projects and suggest them on a large scale instead of having only the power to cut Medicare reimbursement rates.

Jim Landers, a columnist for The Dallas Morning News, also wrote a short column to round out this series that examined the health care systems of other developed countries around the world. None of them are perfect, he concludes, but many have found ways to spend less for equal or better care than that provided in the U.S. I have spent some time comparing our system to that of Great Britain and Canada as well. Like the U.S. health system, each has its own strengths and weaknesses.

My thanks to The Dallas Morning News for its in-depth and informative coverage of the health care industry in Dallas. Surely there was much more to discuss, but their staff did a wonderful job getting straight to the heart of the matter.

The Cost of Care, Part 4

The fourth part of the Dallas Morning News’ five part series called “The Cost of Care” covered home health agencies in Texas and the soaring amount of spending on home health care in the state. You can access the series here.

The article once again aims to examine the fine line between the need for home health agencies and the great services they provide and the abuses of the system and its patients, which can account for a part of the huge increase in costs. It also points to decreases in Medicaid reimbursement rates that some have suggested as a solution to these abuses.

It seems unwise to cut reimbursement across the board for a very necessary service that does much good for patients in order to end some abuses to the system, especially because home care can, in many instances, decrease the cost of care since patients can be treated outside the hospital. Perhaps Texas should re-examine instituting a certificate of need statute as one possible part of the solution.

CHRISTUS HomeCare services are available in Texas, Louisiana and Utah, and we are continuing to invest in those necessary programs. I have blogged before about how we have been realigning our portfolio from its heavy focus on acute care to include one-third non-acute care and one-third international operations because of the trends we’re seeing in our industry and the culture worldwide.

In fact, we continue to believe that advances in technology like remote monitoring devices may make home care services less costly and more effective in the future. They are already assisting us in provide high quality home care today.

Yes, home health care is an important part of the CHRISTUS ministry, and therefore we believe it should remain an important part of the health care fabric in our country.

The Cost of Care, Part 3

The third part of the Dallas Morning News’ five part series called “The Cost of Care” covered the medical imaging industry, which is quickly growing in size and scope. However, some worry that unnecessary scans are driving up expenses. You can access the series here.

The article examines why business is so good for those in medical imaging, which generates $100 billion a year nationally. As The News points out, “More imaging machines has meant significant increases in use, and rising costs for American consumers and taxpayers.”

I have said before that CT scans and MRIs are over-utilized for many reasons, including the fact that patients may demand them because of marketing done by vendors, clinicians may find it easier and faster to do a study rather than spending the time to do an extensive and complete history and physical and because these studies are—at least currently—significantly reimbursed.

The News also quotes a McKinsey Global Institute study, which found that “extra U.S. capacity results in about $26.4 billion in additional costs annually for CT and MRI scans.” The author points to other potential reasons for physician overuse of these technologies, including self-protection from potential malpractice claims, or financial reasons--referring patients for scans to be done on machines they own.

Technologies that have been developed for diagnosis can be extremely beneficial, but can also quickly decrease in overall value because their ease of deliverance and their high financial reimbursement may cause them to become over-utilized. As this technological equipment becomes more affordable, their availability exceeds need and only accentuates the potential for their overuse.

Reform in the U.S. may address some of these issues. (The Texas Legislature has thus far been unsuccessful.) Until then, we will continue to carefully monitor the development and introduction of new technologies, ensure that we’re acquiring and locating appropriate numbers of these technologies in our various regions and business units, utilizing appropriate guidelines to minimize overuse.

The Cost of Care, Part 2

The second part of the Dallas Morning News’ five part series called “The Cost of Care” tackled the doctor-owned hospital dilemma. You can access the series here.

The article does a fantastic job of examining physician-owned hospitals from a variety of angles, admitting that it is a complex issue and that not all physician-owned facilities are created equal. We know that some physician/system partnerships provide much-needed services in a community in an efficient manner. However, we have also seen physician-owned facilities that duplicate services in order to cherry-pick paying patients from the community. These facilities have an Emergency Room in name only—usually a 10 x 10 space—in order to meet legal guidelines, but their main focus is making money, not caring for those in the community who may need it most.

What, then, are we to make of physician-owned hospitals? It is clear that this is an issue where we must tread lightly, examining all the facts before making judgments. While not all physician-owned hospitals exist solely to make money, we must be mindful of the conflict of interest self-referring may involve. It is sometimes hard to distinguish profit motives from patient motives when you are in the thick of things.

As the article points out, data on physician owned hospitals is hard to come by, but my anecdotal experiences with them run the gamut I expressed above. While I believe that all healers have as their highest goal the good of their patients, we have seen some of these hospitals that have positioned themselves to provide only “profitable” care for a small number of patients. We know that physicians must make a living, but doing so in a way that is not in the best interest of a community is immediately suspect.

So we move forward, aware of the pitfalls of and great services provided by physician-owned hospitals. We realize that they, like anything else in health care or life, must be approached with a healthy level of curiosity and—at times—skepticism. Above all, we must do what is best for those we treat, and ensure that our integrity can in no way be maligned as we go about our sacred work.

The Cost of Care, Part I

The Dallas Morning News began a five part series called “The Cost of Care” on the cost of medical care in Dallas in this Sunday’s paper. The news outlet has devoted a section of their Website to this series, which you can access here. It contains polls, interactive maps and links to the online versions of the stories from the series which appeared in print. I would like to take the next few weeks to examine the articles in this series, many of which confirm the positions CHRISTUS has taken for years past.

As health care reform discussions once again overwhelm the news we hear from Capitol Hill, this series is timely and frames the debate well. The articles and vignettes from part 1 of the series, which debuted on Sunday, cover a wide variety of topics, and tell the stories of many local people who can’t afford insurance or struggle to, only to find out in times of crisis that it did not cover their treatment needs. Many of these stories can be accessed online, and I suggest you take a few moments to read them, because they remind us all that the cost of having no or too little insurance is a human one. It is imperative for all of us—health care providers, legislators and regulators—to remember that we exist to serve people, in this case people who are sick and need healing or need preventive care to keep them healthy.

The main article in Sunday’s section aims to answer why Dallas spends more for health care than almost any other big city in America. You may recall this sounds similar to Atul Gawande’s question in his article “The Cost Conundrum, What a Texas town can teach us about health care,” which I have mentioned several times on this blog. The Morning News points out that

In 1992, Dallas was well below the national average in Medicare spending – much less than Fort Worth, Houston, San Diego and 121 other hospital regions across the country. By 2006, spending in Dallas had soared. The Dartmouth Atlas on Health Care now ranks Dallas 13th in the nation, well ahead of Fort Worth and Houston.

The article offers some reasons why this may be occurring, which I have often suggested are the reasons for skyrocketing medical costs. These include
• Overuse and over-prescription of tests and technology. The Morning News says that “Area doctors are seeing patients more often, ordering more tests and doing more procedures.” As I mentioned last week, overuse of diagnostic tests on patients is rampant in the U.S. health care system, and very rarely accomplishes much more than increasing costs.
• Competition causes duplication of costly services, and does not therefore result in reduced costs. The author states that “In other businesses, competition tends to drive prices lower as companies jostle for customers. Not in health care, and not in Dallas. Competition drives up spending.” We have long been in agreement with this statement, which is why we perform a thorough needs evaluation before entering any community. One such evaluation of the Dallas community proved to us that it was over-bedded, which is one reason why the CHRISTUS system has its headquarters in the Dallas area, but is not an acute care provider in this market. We determined long ago that Dallas already had more than enough acute care providers.
• The uninsured and underinsured often delay treatment, ending up in our Emergency Departments—the most expensive place to receive care—when their malady has progressed into something much worse than if we had treated it in its early stages. As a result of this and a gap in government reimbursement, costs for treatment can be shifted to insured patients. The article quotes Gary Brock, chief operating officer of Baylor Health Care System, who said that “ ‘the government reimburses Baylor just 80 percent of its costs for Medicare patients. To make up the difference, Baylor charges privately insured patients 150 percent of its costs.’ “
• Care that is coordinated is best for the patient. The Morning News says that, “A broken market also helps explain a second cost culprit in Dallas. Patient care is not well-coordinated. Once a patient enters a hospital, family doctors say they are left out of the loop. Lots of doctors start duplicating one another's tests, ordering drugs that may interact in dangerous ways and leaving the physician who best knows the patient in the dark.” In fact, family doctors and Emergency Departments or specialists also duplicate tests, driving up the cost of care.
• The U.S. health care system rewards quantity, not quality, and provides perverse incentives for physicians and hospitals to provide more, not necessarily better, care. While we were in Washington, D.C. at the end of July, we had a chance to meet with Mark McClellan, who heads the Engelberg Center for Health Care Reform at Washington's Brookings Institution. We discussed the many proposals coming out of Capitol Hill, and he said much the same thing to us that he said to the Morning News: creating accountable care organizations that pay providers extra for quality and efficiency instead of volume will drive down the cost of care.

The stories told by the Dallas Morning News in this informative series highlight problems with the health care system that are national, not just specific to the state of Texas. Nest week we will examine the second part of the Cost of Care series.

Why all the "to do" about physician integration?

Physicians and their role in the delivery and cost of health care have been in the spotlight recently as the health care debate rages on. Much of these early discussions seemed to result from Atul Gawande’s article in the New Yorker called “The The Cost Conundrum, What a Texas town can teach us about health care” and his follow-up, “The Cost Conundrum Redux.” Gawande suggested that physician overuse and the lack of integration in the care continuum are to blame for the fact that McAllen, Texas has the highest per person Medicare costs in the country. This led to explosive debates around the country about physician liability and integration.

But health systems, clinics and other organizations dedicated to delivering care have long understood that physicians and hospitals, while sharing the same goals, may seem pitted against each other. It is for this reason that physician integration is key to success for health systems and the joint delivery of high quality, low cost care.

The following graphic shows how this integration occurs, but the boxes about the differences show why achieving that it so hard.


How might we bring hospitals and physicians together? We may implement the following strategies for change:
• Set expectations for team process
• Train and educate the team together
• Plan together
• Implement and operate together
• Performance goal setting
• A performance appraisal process
• Shared incentive for financial gain

Ultimately, however, I believe we must gather both groups around the common goal of providing high quality, low cost care using evidence-based protocols. Both groups understand that they have a sacred responsibility to care for human life, and most view this as their definitive purpose. This must be what brings us together.

Remembering the Human Touch

One of our Associates recently sent me this story, written by a physician who urges doctors to return to the healing power of touch, and cautions that the rush to use the latest high-tech diagnostic tools often ignores the intrinsic value of a physical exam.

As I have often said, one of the reasons for the skyrocketing cost of health care is not misuse, but overuse. The author of the article avoided costly tests (ultrasounds, CAT scans, MRIs) to diagnose the patient’s condition by merely touching her, but this was not her first line of thought.

It also impresses upon me the importance of family practice physicians and physician extenders, who—it seems to me—generally have a much greater tendency to rely on their diagnostic skills.

We constantly hear the excuse that physicians are worried about liability, and therefore utilize more technology both in lab and radiology to, in essence, protect themselves from unmerited malpractice suits. This is why we have been so clear that tort reform must be included in national health care reform. I will not rehash the CHRISTUS experience with tort reform in Texas in this post, but feel free to visit a previous post on tort reform to learn how successful we believe it has been thus far.

If we as physicians could return to utilizing more physical diagnosis and not worry about liability before jumping to the use of technology, we would go far in reducing overuse and misuse in the health care industry.

The case Dr. Castro described in her article demonstrates that hypoglycemia is the most common cause for diabetic confusion (which is quickly diagnosed from confused dialogue with a sweaty patient). This patient could have been sent for a CAT scan or MRI, during which she could’ve suffered ongoing and probably permanent brain damage from her persistent low blood sugar.

Learnings from Comparing and Contrasting the British & U.S. Health Systems

As the U.S. health care debate accelerates, it continues to be important to compare and contrast the U.S. health system with those of other countries as part of our learning journey.

Our travels for our Futures Task Force II work provided us with an opportunity to grow some knowledge of the health care delivery systems in both Canada and England.

The National Health System (NHS) in Britain is celebrating its 61st birthday in 2009. At face value, comparisons between the U.S. health care system and the NHS are stark and have caused quite a debate.

The NHS has a “socialized system.” Socialized medicine is a term more commonly used in the U.S. and usually refers to publicly financed and/or government-administered health care. It has taken on a pejorative meaning and evokes negative sentiment toward public control of a health care system. Ultimately, each system around the world, regardless of what it’s called, aims to find a solution that best meets the needs of its country’s population. One could argue that the U.S. has aspects of a socialized system with its Veterans Administration and Medicare and Medicaid programs.

Understanding the origins and evolution of the NHS helps to contextualize changes in U.S. health care and to highlight strengths and weaknesses in both systems. The NHS was established by the Labour Party in 1948 against considerable opposition as a small component of a wave of postwar nationalization. Before its creation, patients were generally required to pay for their health care. The founding principles of the NHS called for health care services to be:
• Provided free at the point of use,
• Accessed by all people (even those temporarily resident or visiting the country) and
• Financed from central taxation and not through national insurance.

The NHS has changed considerably in the intervening years. Organizational restructuring in the 1960s integrated NHS primary and secondary services under single regional bodies, a process which has continued. An end to economic optimism in the 1970s and 1980s led to the introduction of modern management processes, which still dominate the Service. Sustained investment by Prime Minister Tony Blair’s government during the 1990s aimed to modernize and streamline the Service through the introduction of internal and external competition, closure of surplus facilities and introduction of efficiencies (including the elimination of long waiting lists). In recent years, the achievement of efficiency in the NHS has placed a renewed focus on quality and innovation.

The NHS provides a vast array of services. An annual budget of £90 billion (U.S. $135 billion) has produced some impressive results compared with other health systems, and the NHS consistently ranks higher than the U.S. in several global health surveys. In 2007, the Commonwealth Fund compared the performance of five nations—Austria, Canada, Germany, New Zealand, The U.S. and the UK—on five dimensions of a high-performance health system: access, efficiency, equity and healthy lives. Overall, the UK ranked the highest across these metrics, and the U.S. the lowest.

What has probably been most surprising is the unique sense of ownership and social responsibility people have for the health service. Major initiatives, such as the closure of an NHS hospital, are presented to the community for public consideration. In another example, the board of a pediatric hospital in the North of England actively sought feedback from community children on what they value most in their experience at a hospital.

At the same time, there is the National Institute for Health and Clinical Excellence (NICE), which plays a unique and valuable role in prioritizing new technologies and drugs. But NICE also creates a culture of conservatism that results in slow adoption and sometimes limited patient choice for very innovative practices and technologies.

As the NHS continues to evolve its system of care (I.e., the entire care continuum of inpatient and outpatient services), NHS chief executives and managers are looking to the U.S. for leading practice approaches to more systematic and collaborative care that have been achieved by such organizations as Kaiser Permanente and Geisinger health. As the NHS has shaped its model over the last 61 years, it has done a good job learning from the past and from the experiences of others around the world while finding the best available evidence to support its planning.

An NHS model would be a radical cultural shift for U.S. health care. But ultimately, we will find a solution that makes sense for us just as other countries have managed to do.

Rationing Health Care

Before I begin my blog post today, I would like to extend my sympathy to the Kennedy family on the loss of Sen. Ted Kennedy. Regardless of one’s political views or affiliations, it is clear that yesterday, health care reform lost a great friend, and our country lost a great legislator and a bright light upon the death of Sen. Kennedy. His legislative legacy is great, but I am disappointed that the great man who fought for health care coverage for all Americans since 1966 did not live to see the current reform initiatives brought to fruition.

As the health care reform debate reaches a fever pitch, one of the constant concerns being expressed in public forums and congressional offices is that reform will bring about the rationing of health care, meaning the government or some designated body will be given the ability to control when and what services are provided to patients.

In reality, rationing is occurring in health systems in some form all across America today. People are denied access to primary care appointments, must wait in line to see some specialists, are told by some physicians that their conditions are not severe enough and should wait for further deterioration or increasing pain before a “curative procedure” will be provided, etc. In addition, blood bank supplies are not endless, and often borderline anemic patients do not receive transfusions that are given to patients who are much more critically ill or who suffer from trauma or having large procedures on their heart or vascular systems.

Clearly, as new technologies such as contrast-related MRIs and robotic surgical robots are developed, they are slowly made available as they are tested and made more affordable, during which time they are extremely limited to small populations of people who are in the right place or whose financial situations or insurance gives them the opportunity to take advantage of this service during this initial startup phase. This is one way in which rationing is a part of our health care system every day—new technologies are available only to a select few who can access and afford them.

But an even clearer example of rationing is in the area of dialysis, a much more common procedure which is increasingly utilized by a larger number of people in America in order to sustain their lives until either their kidney disease is reversed with new and more modern medicine, or kidneys become available through live or cadaver donors. When dialysis was first developed, just like the initial MRI, the procedure was only available in the very largest of health centers, and was only provided in a very high cost and intensive inpatient setting. During this development phase, there were many people who could not avail themselves of this much-needed procedure, and hence died. In addition, because the number of people who could benefit from dialysis--even at the centers that were fully operational--exceeded the staffing and machine capabilities of these centers, the patients were prioritized according to the ones who would receive the most benefit from these limited services, and the others were denied access.

Clearly, this was rationing at its best and worst. Because the life-saving technologies both proven and yet-to-be developed will never meet all the needs of every person who might benefit from them, either permanently or temporarily, those who would only receive marginal benefit from such technologies will inevitably be put on a waiting list, never reaching the point on this list where those services will be available.

Fortunately, over the years more and more evidence-based scientifically driven protocols have been developed that defined--to the best of the provider’s ability--those patients who will receive value from each and every process and procedure. Where there are excessive resources, everyone who will benefit will receive the appropriate care. However, the downside of excessive resources is that many people who would not benefit from such procedures will inevitably receive them also—the overuse of health care. This is truly the negative side of rationing.

So although the recent health care dialogue has escalated the concern that the government or a government-related entity will decide who will receive specific health care and therefore decide who will live and who will die, the fact is that rationing has been, is, and will always be a part of the health care environment. The downside is that yes, occasionally there is someone who could benefit from the care who will not receive it. This is the underuse of health care. But in my 41 years of experience, I have rarely seen a case where such occurred. A person who really needs and can benefit from a procedure will find a provider who will make that happen by utilizing, at times, referral patterns and processes that are non-traditional, much like the child in California living in a low-income home who required a highly technical lifesaving cardiac procedure who was flown by a volunteer pilots association to CHRISTUS Santa Rosa Children’s Hospital in San Antonio, where the procedure was performed free of charge, both by the physicians and the hospital.

In contrast, without the need for rationing, the misuse and overuse of health care, the major drivers of the high cost of health care, quickly occur, i.e., the cardiac cath that could be avoided, the stent that did not need to be put in the borderline patient and the MRI or CAT scan for which a simple physical diagnosis or skull X-ray could suffice for a patient, particularly a pro-football player who suffered a mild concussion.

Yes, rationing is necessary, and should be supported. The concern should be that it will be done by people who have no medical background. Necessary and good rationing can and must be done by people who are well-trained and committed to the highest quality, low cost medical care which demands that proper use rather than over-, under- or misuse is the guiding principal.

Customer Service and Patient Satisfaction

Good customer service springs from individuals within an organization. It requires compassion and understanding that it is only by putting the needs of our customers, patients and residents first during each and every interaction with them that we can hope to excel as an organization and ensure we are fully living out our mission.

By the very nature of our work in health care, we are fortunate to have the opportunity to serve others at a time when their need for compassion is greatest. We are a privileged few.

In my message to our Associates this month, I congratulated each of them who have worked so hard in exceeding our patients’ expectations to provide the kind of compassionate, exemplary service we want to be known for at CHRISTUS. Service is not something we “add” at the end of the day or when we have time. Instead, it is a specific attitude toward caring that must occur as we do our jobs and interact with patients, their families, Associates, doctors, vendors and, essentially, each and every person we interact with each day.

I also told our Associates that, overall, patient satisfaction scores at CHRISTUS Health have improved significantly over our first decade of operations in the areas of inpatient care, emergency department (ED), outpatient and ambulatory surgical services.

The system has focused intensely on improving the ED patient experience during the past year. As a result, CHRISTUS achieved its largest single-year improvement ever and exceeds Press Ganey’s national average for the first time. Satisfaction improves dramatically when patients spend less than 2.5 hours in the ED, so efforts to streamline patient flow will continue to be important. Responding effectively to patient concerns and complaints is our greatest priority for improvement across all services. Hence, this will be a key system focus during our next fiscal year.

Commitment is the foundation of CHRISTUS’ Service Guarantee. The focus of our guarantee is a pledge that we are going to succeed, by being compassionate, attending to our patients’ special needs and keeping them informed, just as we would want to be if we were in their shoes.

Taking a break from reform to talk about bringing CHRISTUS to the next level via team building

I’d like to take a week off of our focus on health care reform to blog about something that will be of the utmost importance as we move forward, regardless of the outcomes of the reform discussions on Capitol Hill.

I firmly believe that CHRISTUS—and all health systems that expect to continue providing care far into the future—will need to ensure that it has the best and most appropriate leaders in place in order to meet the challenges and opportunities of the future.

So earlier in the year, I made it clear once again to our regional leaders that they are critical to ensuring that our Journey to Excellence in the future is even more successful than it has been for the last decade. Our regional CEOs and those with whom they work are the most critical success factor in reaching our benchmark goals.

Even so, while the action of individual leaders are important, what our leaders do with their respective teams is even more critical if CHRISTUS is going to create an excellent experience for all who enter our doors. In these challenging times, the strength of the team is often weakened, and at best, not enhanced. But it is my belief that it is critical that we all focus on a process that has the potential to strengthen our teams, as well as every team, that works within the large CHRISTUS Health family both in the U.S. and Mexico.

Therefore, along with the CHRISTUS Health Senior Leadership Team, we articulated 14 Attributes of Excellent Teams, 10 of which I have used for more than 40 years in developing strong teams both clinically and administratively (which you can read about here), and four of which added in discussion with the other nine senior team members. The additional four attributes include: 1) team purpose, 2) results-driven with recognition, 3) prayerful reflection on team and performance and 4) complementary.

We then requested that our regional CEOs share these attributes with their team members in a face-to-face session and, following a discussion, have each of their team member’s rank – on a scale of one to 10 – where they perceive their respective team is on each attribute.

After calculating the team average for each of the 14 attributes, the regional CEOs and their teams were asked to develop action plans to be implemented through Fiscal Year 2010 to improve all of the attributes in which they scored a seven or less. In addition, we asked these CEOs to take accountability to continue the process so that eventually, by June 2010, every person within CHRISTUS Health, all of whom are a member of some team, somewhere, will be actively contributing to initiatives which are hopefully providing value to our ministry.

These continue to be challenging times in health care, made worse by the global economic crisis. However, as always, we find these times exciting and see multiple rainbows emerging from the clouds. Leadership in health care is an awesome responsibility, and at times, can be very lonely. Therefore, in the best and worst of times, the effectiveness of the team is critical. So in this moment in time, we are making sure that we do everything possible to strengthen our team so our Journey to Excellence continues to not only be successful, but for the most part, enjoyable and rewarding.

What Do I Do All Day?

I’m periodically asked by younger health care leaders, including physicians, what I do all day

It may seem that handing them my job description would be a sufficient to answer their query. However, what they really want to know is what general areas do I focus on—how do I spend my time--and how that might be different today compared to my leadership schedule in the past.

I quickly respond by saying that the areas I concentrate on today are somewhat different than in the past, both in description and function. My work week can generally be divided into the following areas of responsibility and accountability:
• Operationally-focused CEO Whereas CEOs of the past often relied totally on their COOs for day-to-day operational efficiencies and fiscal stabilities, today a successful CEO must be able to articulate, at least at a high level, what operations is doing, what improvement plans are in place and what future operations will look like quarter-to-quarter. Audiences ranging from the system board to bond raters and investors expect me to speak to these areas in a credible way, demonstrating a far greater depth of understanding than would have been expected in the past.
• Creating a sound vision for the future There is no question that in the increasingly challenged health care industry, keeping people focused on a clear vision/direction for the system is key. This vision must be easily articulated and understood by Associates at all levels of the organization. Much of my time is spent with management and governance teams, discussing this very topic.
• Understanding the “change” agenda Many CHRISTUS strategies and tactics have to do with maintaining the status quo while making it more efficient and effective. However, critical to our success are certain areas which must be radically changed. It is imperative that I spend as much time as possible on not only identifying these areas, but paving the way for change.
• Teaching, coaching and mentoring future leaders Prior posts on my blog have been written on this key success factor. It will always be true where we are successful, we have the right leader and where we are not, we don’t! It is our job to make sure that those to which we give responsibility are sufficiently educated to lead effectively and accept accountability.
• Balance “present” and “future” time and energy If the present does not work, there will be no future without substantial investment. The money we spent on Futures Task Force II will have been wasted if our cash flow cannot sustain current operations.
• Creating the culture of the organization For us, that has been creating a culture of excellence built on the foundation of our mission, vision and values. This is done through constant focus on the 4 directions of our Journey to Excellence, connecting everything we do to them. Because no consultant or association can pluck a culture off the shelf and make it work, I must walk the culture walk and talk the culture talk each and every day.

Back again

I’ve taken my blog back, but am on the road again and have decided to take a break this week from blogging. This would be a great time for those of you who weren’t able to keep up with our blog posts from D.C. last week to look them over now.

Blog: Hijacked!

Day 1: Disaster Preparedness, Health Care Reform and Health Care IT (written by Abby Lowe)

Video: One stop on our whirlwind tour

Day 2: CHRISTUS is Unusual (Written by Abby Lowe)

Day 3: Change is Hard, but our CHRISTUS Family Does it Well (written by Abby Lowe)

Video: We did this all week long

Day 4: Health Care Reform: What does it mean for me, my neighbor, and Ronnie? (written by Abby Lowe)

Health Care Reform: What does it mean for me, my neighbor, and Ronnie? (written by Abby Lowe)

In retrospect, this was a perfect week to come to D.C. We talked to legislators, regulators and policy experts who are smack dab in the middle of negotiations on health care reform as we traveled around telling the CHRISTUS story. We pumped the journalists we talked to for information, and we exchanged ideas with national thought leaders. We inserted ourselves into the thick of things, provided our own expertise and learned a lot in the process.

We’ve learned that so far, there are few particulars on exactly what health care reform in the U.S. will look like. Lots of people have ideas about how things should go (some good, some not so much), and it can be difficult to pin down an exact position on anything. But we do understand that everyone—insured and uninsured, rich and poor, young and old, providers and patients--will have to give something up to make sure we come out on the other side with an equitable system that works for everyone.

One of the things I heard Dr. Royer say quite a bit this week was that reform needed to be patient-focused. “What’s best for the communities and the people we treat?” he’d ask.

And that got me to thinking of Ronnie.

Our Health Care System is Broken

I met Ronnie during a year I spent in inner-city Oakland, California. From the fall of 2004 to the fall of 2005, I lived in a tiny apartment with four other young women and spent half of my week volunteering in an elementary school and the other half providing foot care for homeless men in a clinic downtown.

Most people don’t realize that many folks who are homeless deal with extensive foot pain because they walk around all day and can’t take their shoes off at night (because they’ll get stolen) or when they get soaked in the rain (because they rarely have a pair to spare). So we trimmed their toenails, shaved their calluses, listened to their stories and sent them off with a clean pair of socks.

But one slow Tuesday, a guy in a wheelchair showed up at our clinic door with a bandage around the left side of his face and over his left eye. He was emaciated, weak and covered in dirt.

His name was Ronnie, he told us. A failed suicide attempt had left him paralyzed from the waist down, and skin cancer had eaten away at his face.

He took the bandage off to show one of the clinic nurses his wound, and I was shocked.

I don’t know if the wound actually was the result of skin cancer, but I know that it was so deep that I could see his cheekbone, and it had a horrible, rotting smell. (I did foot care two days a week for homeless guys, and yet I had never seen or smelled anything like it.)

Ronnie explained that he had slept in a park the night before, and had woken up to realize that there were ants crawling in and out of the huge gaping hole in his face. He just wanted some help, to be sure it was properly cleaned before he went on his way.

So the nurse, God bless her, cleaned his wound, gave him some more gauze and bandages and slipped him a sandwich or two before he left.

As he wheeled himself away, I felt somewhat defeated. Ronnie obviously needed much more care, a clean place to sleep and behavioral help than we could not provide.

Ronnie needed a health care system that worked for him. And while we had done what we could, we had ultimately let him down. He could not get or afford the long-term care he needed, and the care we provided him at our tiny clinic would never be enough.

I will never forget the first time I saw Ronnie’s scrawny frame dwarfed by his wheelchair, feeling my heart break at hearing his story. And I will certainly never forget the stench of his rotting flesh. I want health care reform for Ronnie.

And I want health care for a man we met yesterday, whose wife was diagnosed with breast cancer a little over two months into her second pregnancy. They had insurance, but couldn’t get clear advice on what to do, what was best for this woman and her baby. They visited many specialists and got many different answers. The male doctors said one thing, the female doctors said another. The oncologists said one thing, but the surgeons said another. Finally, they found a reconstructive plastic surgeon who helped them navigate their options and her care. Today, their child is a healthy four-year-old, and this man’s wife is still in remission. But the system did not work for them—in all its convoluted brokenness, it caused them pain, confusion and fear instead of assisting them in their time of need.

They deserve better.

The Truth Hurts

But I have to be honest. I’m a normal, everyday kind of person. And although I consider myself compassionate and informed and I care about what health care reform means for Ronnie, I also care about what it means for me, that insured gal who (thankfully) has mostly used her insurance coverage for preventive care, to treat small colds/sinus infections and to offset the cost of prescription medications.

I also want health care reform for me.

The New York Times reports that:
”Our health care system is engineered, deliberately or not, to resist change. The people who pay for it — you and I — often don’t realize that they’re paying for it. Money comes out of our paychecks, in withheld taxes and insurance premiums, before we ever see it. It then flows to doctors, hospitals and drug makers without our realizing that it was our money to begin with. . .”

”The United States now devotes one-sixth of its economy to medicine. Divvy that up, and health care will cost the typical household roughly $15,000 this year, including the often-invisible contributions by employers.”

Health care reform is important for all of us, and we’re in it together.

It was in our inner-city neighborhood in Oakland, walking past discarded drug paraphernalia that lined the streets, where loud music filled the air and our poverty-stricken neighbors reach out to us, fed us, protected us and invited us over to watch cable TV that I learned that everyone--no matter what kind of job they do, the level of education they’ve achieved or how much money they earn--is basically the same. We all deserve to chase the American dream as healthy, whole individuals.

Ronnie deserves it, wherever he is. And so do you.

Now’s the time. Dr. Royer started the CHRISTUS system on this journey this week in D.C. Will you join us? ~Abby

We did this all week long

Members of the CHRISTUS team meets with a senator’s Chief of Staff and other stakeholders in the Senate Reception Room to tell our story

Day 3: Change is Hard, but our CHRISTUS Family Does it Well (written by Abby Lowe)

Once again today, we met with journalists, legislators, regulators and policy experts to tell the CHRISTUS story. We also got a chance to meet with a representative from the Mexican Embassy, which allowed us some time to fill him in on our operations in our CHRISTUS Muguerza region.

It seemed like we spent a little longer sitting down with folks today so we could really focus on building relationships. After all, Dr. Royer is here not only to tell the story of the CHRISTUS family, but also to make it clear that CHRISTUS has a different focus than many other health systems, is forward-looking, and would like to help with health reform or any other issue that they might want information, education or resources on.

One thing that struck me as I sat in these meetings was an overwhelming sense of pride in CHRISTUS and the work done by CHRISTUS Associates every day. Dr. Royer, Peter Maddox and Patti Harper have spent time telling our story to all sorts of groups, including the head of FEMA, the LA Times, the U.S. Department of Health and Human Services and even Mark McClellan (who served both as FDA Commissioner and head of the Centers for Medicare and Medicaid services).

They continue to focus on the unique things CHRISTUS Associates are doing across our diverse system. They talk about our futures planning (especially Futures Task Force I and II), and how those learnings have changed our system. They talk about our experiences with hurricanes, the great sacrifices of our Associates to care for patients and each other in affected regions and what can be done better in the future. They talk about the fact that we’re not building more inpatient beds, and even about the CHRISTUS Stehlin Foundation for Cancer Research in Houston, which we believe has made some advances that will revolutionize cancer care in the next 10 years.

I wish everyone could see the faces of the folks Dr. Royer meets with as he tells many parts of the CHRISTUS story.

They are surprised. They are impressed. They have lots of questions about what we’re doing.

They’re stunned to hear that we don’t agree with the American Hospital Association (AHA) and even our state hospital associations on every point of health care reform. We have been honest about the fact that we’ll need to make some concessions if reform is to pass. We won’t give away the whole shootin’ match—obviously, we must remain financially viable to continue to serve the members of our community—but CHRISTUS is not willing to let perfect be the enemy of good.

We’ve heard that we will see some kind of reform legislation this year, but it might not be as sweeping as the changes being considered now. And I’m sure many of you heard today that these reform discussions will not be done by Congress’ August recess.

But we’ll also be in touch with representatives while they are at home over this break. It will be another great chance to explain what we’ve been saying about health care reform: it’s necessary, it’s urgent, and it must be done correctly now.

Dr. Royer often reiterates the fact that most of the excess cost in health care is from overuse and misuse, not under-use by uninsured populations. (If you’re really interested in this topic, I’d suggest you read an article written for the New Yorker about McAllen, Texas. You can access it here. It’s a lengthy write-up, but it really clarified the health care reform discussions for me.)

It’s become clearer to me that people are people, wherever they live and whatever they do. These health care reform discussions may seem scary for many Americans who are concerned about cost containment. They are scary for those who have insurance that they like. And they are scary for many health care providers, who are worried about what these changes will mean for them.

That’s understandable. And it’s one of the reasons that Dr. Royer is here telling your story, explaining about the progress that the members of the CHRISTUS family have made in our 4 directions on our Journey to Excellence. These improvements prove that high quality care can be provided at a low cost, one of the main focuses of health care reform.

Change is hard, and almost no one likes it. In many ways, the known evil seems less threatening than the unknown. But in this case, the known evil is 46 million Americans without adequate access to care, rampant overuse and costs in the provision of care all across the country, reimbursement that doesn’t make sense (and should fairly include preventive care) and no end in sight to these issues.

Now’s the time, so we continue with meetings tomorrow. Once again, we’ll keep you in the loop. ~Abby

Day 2: CHRISTUS is Unusual (Written by Abby Lowe)

Today I’ve been as sponge-like as possible. I sat in on meetings with Republicans, Democrats, Senators and Representatives. And while today’s discussions really focused on health care reform, Dr. Royer and Peter Maddox did speak about hurricane/disaster preparedness once again.

We had our first meetings with journalists today, where we answered their questions about our opinions on specific reform bills. We also spent an extensive amount of time introducing CHRISTUS, telling them about our Journey to Excellence, our experiences with tort reform, our portfolio realignment (to 1/3 acute care, 1/3 non-acute care and 1/3 international care), our partnerships in Mexico and our experiences caring for patients in some of the states with the highest uninsured rates in the U.S.

And through all of these meetings, I came to understand one important fact about CHRISTUS Health: we are weird.

I think all the legislators we met with today were shocked that we did not come to ask for more money, or to complain about health care reform. No, we came to express our support, to tell them our views about what we thought should be included, and to ask what we could do to help them in their negotiations.

And it was clear that the fact that we came in to listen as much as we came to talk and that we weren’t carrying a “No, no, no” message meant that the legislators and their staffs were much more open to sharing openly with us and hearing what we had to say.

Dr. Royer says the same things to all of them about health care reform. We support reform, and believe it should, at the most basic level, be:
• Available and accessible to everyone, paying special attention to the poor and vulnerable.
• Prevention-oriented, with the goal of enhancing the health status of communities.
• Sufficiently and fairly financed.
• Transparent and consensus-driven in allocation of resources, and organized for cost-effective care and administration.
• Patient-centered and designed to address health needs at all stages of life, from conception to natural death.
• Safe, effective and designed to deliver the greatest possible quality.

It should also include tort/medical malpractice reform, which has been a winning formula for CHRISTUS in Texas. Tort reform caps medical malpractice awards for noneconomic damages at $250,000. This means that patients who are injured by negligent medical care retain the right to full recovery for their economic damages. The people of Texas reap the rewards of tort reform as they see doctors returning to high risk locations and high risk areas of practice and as they see hospitals providing new resources for more and better medical care. Texas has become a role model for a fair, practical and lasting approach to medical malpractice reform. You can read more about the CHRISTUS experience with tort reform here.

Health care reform, Dr. Royer says, should also align physicians and hospitals, standardize care based on evidence-based principles across the country and provide quality-based incentives.

Everyone we’ve met with so far has seemed to be very open to these suggestions and interested in our experiences.

Tomorrow we meet with the Mexican Embassy, regulators and journalists. I’ll do my best to keep you up to date with all the news that’s fit to print! ~Abby

One stop on our whirlwind tour

One visit we made today was to check in with the staff of Rep. Matheson (D-UT). I thought I'd let Dr. Royer fill you in on the visit. (Seems like the right thing to do since this is still his blog. . .)

Day 1: Disaster Preparedness, Health Care Reform and Health Care IT (written by Abby Lowe)

Wow. I obviously should’ve worn more sensible shoes today.

I’m exhausted, but Dr. Royer just keeps moving right along. (“I’m not tired until the work is done,” he says. And even though I’m 30 years younger and even though he probably woke up around 4:30 or 5 this morning, I seem to be the one dragging.)

It was a great first day of meetings, though. We met with the staffs of 2 senators and 1 congressman, an expert in health care IT who is charged with helping HHS regulate recent funding requirements and some of our friends at the Catholic Health Association who are very involved in health care reform and have attended quite a few meetings at the White House.

We talked some health care reform today, but mostly carried messages about disaster preparedness—how state and local governments could work better with us and with FEMA to help us be more effective during hurricane evacuations and help us better care for our patients, and the legislative changes we’d suggest to help that process along. Obviously we talked about health care IT--the American Recovery and Reinvestment Act of 2009 (ARRA) provided approximately $19 billion for Medicare and Medicaid Health IT incentives over five years, so we and other health systems want to stay engaged in those discussions.

I might take some time later in the week to delve into health care IT and disaster preparedness, but I learned quite a bit about health care reform today that I think you’ll find interesting.

My head is still spinning, and I can say that even though I do my best to keep up with the health care reform discussions, I have trouble keeping up with who said what, what’s included in a suggested bill, what’s not, what’s been thrown out, who’s working with whom, who feels like they haven’t been invited to the table, etc. It’s a dizzying mix of conversations, negotiations, he said/she said, and it all feels like it’s moving very, very quickly.

But we met today--and will continue to meet--with legislators on both sides of the aisle—Democrats and Republicans, conservatives and liberals. We also heard from some of our colleagues at the Catholic Health Association who speak on our behalf. Here are some things I learned:

1. You can’t let perfect be the enemy of good. The bills being bandied about on the hill aren’t perfect. No bill of any kind on any subject ever will be, but the 46 million Americans without insurance can’t wait. A recently released report by the Institute of Medicine makes clear that Americans without health insurance live sicker and die sooner. And they can’t afford to wait 15 more years for real health care reform.

I also learned that 28 million of the uninsured are small business owners and employers. And it sounds like many of them would be happy about being able to afford insurance coverage.

2. A solution crafted this year won’t be a permanent fix. The bill that is crafted now may work for the next 10 years or so. But given the advances we expect to see in medicine and technology, it may not be appropriate for the 10 years after that.

3. We aren’t here asking for no cuts to Medicare/Medicaid, but we have drawn some lines very firmly about what we will not accept. Hospitals have agreed to $155 billion in cuts over the next 10 years. It sounds like we will be able to cover these costs, provided that the majority of Americans emerge with health insurance coverage. However, we would never stand for cuts in dollar amounts that we could not manage. (We could not shoulder cuts that reached as high as $300 billion, for instance. And after all, what good is insurance if no hospitals can afford to stay open to provide care?)

As a Catholic system, CHRISTUS would not support any kind of reform efforts that included threats to life like abortion. From what we heard today, it does not sound like the current discussions will form a bill that addresses abortions in any way.

4. I heard someone say today that health care reform will cost $2 trillion. $2 trillion is a whole lot of money. It sounds like WAY too much to pay for anything, no matter how it is financed. (Including health care reform.) But the insured of our nation are already carrying that kind of burden. Did your insurance costs go up this year? Mine did. Apparently our costs have been rising for years and CHRISTUS has been carrying that cost, but it got too large for CHRISTUS to carry anymore. So some of that cost was shifted to me and the rest of our Associates on the CHRISTUS plan. Insurance premiums will continue to rise, because insured patients carry much of the burden of health care costs. They don’t carry it all by any means, but many people treated in hospitals cannot pay for their care, and that cost is passed on to those who can.

I also understand that $2 trillion is probably not the most correct cost. I believe the Congressional Budget Office estimated the cost closer to $1 trillion, which does not at all include new accounting rules or the concessions made by industries like hospitals. Legislators are also still working on the final plan, and I believe more cuts in that nunmber will be made. For more information on this, I suggest this article.

5.Being here obviously brings back some Schoolhouse Rock! memories. I have “I'm just a bill / Yes, I'm only a bill / And I'm sitting here on Capitol Hill” stuck in my head.

But we have three more days of jam-packed agendas to get to, and I’m exhausted but excited to see what comes next. Stay tuned! ~Abby