Wednesday, August 25, 2010

Creating an ACO: An Ethical Issue?

I’ve blogged before about Accountable Care Organizations (ACO) and reform. ACOs were one of the few specific programs mentioned in the Patient Protection and Affordable Care Act, and have therefore received much attention from health care organizations around the country.

But perhaps more important than the “how” of ACOs is the “why” of ACOs. It is the hope of health care reform that by better integrating care for a person across the health care continuum, we will, as providers, be able to improve quality of care and patient safety while reducing costs. In a recent article appearing in the July/August 2010 edition of Healthcare Executive, this outcome was characterized as “The Ethical Basis for Creating ACOs.” The authors indicated that organizations, like CHRISTUS Health, “have a moral imperative to deliver cost-effective, high-quality and safe health care.”

The authors also wrote a small section on being stewards of health care resources, one of the important guidelines embedded within our values. Hence, it appears that with our strong commitment to becoming a high quality low cost provider, driven by our values and organizational ethics, that CHRISTUS Health can develop an ACO that is a trusted resource for health and wellness care, serving as both a national and international model.

Wednesday, August 18, 2010

Reaffirmation of CHRISTUS Health’s Balanced Scorecard

In December of 2006, three CHRISTUS Health Associates published an article in hfm, the journal of the Healthcare Financial Management Association (HFMA), entitled, “A search for the ‘Holy Grail’ of Healthcare: A Correlation Between Quality and Profitability.”

In the article, CHRISTUS sought to ascertain whether there is a favorable, statistically verifiable relationship between quality and financial performance. This effort echoes an industry-wide search for what might be labeled “the Holy Grail of health care”: statistical documentation that improvements in quality, patient safety and clinical vigilance are significantly correlated with profitability and measures of financial success. CHRISTUS Health sought validation that spending on quality care and patient safety constitute a genuine investment in improved profitability and viability.

Our results clearly showed the correlations between quality and financial performance. The findings thus gave hospitals strong evidence that well-executed clinical quality initiatives will contribute to improved financial performance. The article concluded that,” As an industry, we cannot claim to care for patients if we are unwilling to make an unwavering commitment to quality. But neither should we be expected to compromise our organizations’ financial well-being for the sake of clinical quality.”

Recently, a reaffirmation of our findings which support the use of a balanced scorecard to monitor our Journey to Excellence was published on HFMA’s Website with the headline, “Higher Hospital Margins Distinguished by Higher Patient Satisfaction.”

According to data from the Centers for Medicare & Medicaid Services (CMS), there is a distinct relationship between a hospital’s profitability and its level of patient satisfaction. CMS collects and reports measures of patient hospital experiences based on the Hospital Consumer Assessment of Healthcare Providers and Systems survey instrument. Data are collected for all patient types (i.e., not just Medicare patients). Currently, measures reflect patients’ responses to 10 questions regarding their experiences with an overnight hospital stay.

This analysis looked at patient responses regarding hospitals’ overall ratings and whether patients would recommend a facility. The percentages of patients answering “High” as to the overall rating (options were High, Medium and Low) and answering “Definitely” as to whether they would recommend the facility (options were Definitely, Probably and No) were calculated for each facility for the survey period ending March 31, 2009.

Hospital margins were then calculated for each reporting hospital from Medicare cost reports for periods ending in CY08. The results showed a clear relationship between higher margins and higher ratings. The median operating margins were positive only with higher satisfaction ratings. Using the same approach, the study found the same relationship between profitability in perceived quality in that higher profitability was seen in hospitals where a patient said they would recommend the hospital to others.

Because the Journey to Excellence, its four Directions and the results of the balanced scorecard have been an integral part of the CHRISTUS Health brand since we began in 1999, it is most reassuring from both of these studies to know our focus has been a key critical factor in our success.

Wednesday, August 11, 2010

What has changed in health care?

Lately, I’ve been looking back on my career thus far and considering how I may continue to serve patients and the health care industry in the future. Part of this process has included looking over and reorganizing articles I have written over the years, and it appears that we are still confronting issues that I was writing articles about 10 years ago.

In 1998, I wrote an article for Crossroads magazine called "The Courage to Change" about how physicians must transform their behavior so they could begin to think in terms of populations or preventions by becoming schooled in the economics of health care delivery, beginning to talk openly about outcomes with other physicians, accept input from patients and share clinical responsibilities with non-physicians. I made the case for change toward population-based medicine and care management strategies that view patients, disease and health through a wide-angle lens.

One could argue that health care reform aimed to end a compartmentalized approach to health care and align incentives so that providers are rewarded for providing better outcomes instead of more care. While I spoke of the necessity of these things in 1998, it is clear that improvement in this area is still a necessity today.

And while we as physicians and caregivers have come a long way in recognizing and adhering to practice guidelines, clinical pathways, practice profiles and outcome comparisons to generate evidenced-based improved clinical results, our work is far from over. We must continue to challenge ourselves—and one another—to measure up to the higher standards for outcomes, service and resource utilization that we know are possible.

Wednesday, August 4, 2010

As we predicted

The Wall Street Journal recently ran a story entitled, “Americans Cut Back on Visits to Doctor”. This story reflects our belief that health care usage in a weak economy would decline, particularly in acute care settings.

Instead, people are seeking alternative and complementary medicines and self-medication/treatments to address some of their medical conditions, and are certainly re-evaluating the need and timing for elective procedures. Understandably, we have seen a major shift occur, and I don’t believe care access patterns will EVER return to what they were before. (Please do not hold your breath hoping that “the good old days” will return, and do not keep looking for “another flu season”!)

This article clearly supports our position and thinking, and examines the eventual need for insurers to reduce their premiums to continue to capture the business. What does this mean for the CHRISTUS Health ministry?

1. We cannot rely on increases in volumes and increases in reimbursements to create better revenue streams for us. We have been saying for several years that revenue increases will only come from volumes created by organically-growing communities in markets where we are stealing market share, or where we can add new profitable service lines that the community values. Volume increases will not occur from our “same-store book of business.”

2. If people are going to doctors less, then less hospital admissions will be generated. Our CFO and I were on a call recently with the health care bond rating team from Standard & Poor’s, who we began bond rating sessions with in 1999. Their data again shows that inpatient volumes are down 7 percent across the U.S., and that outpatient volumes are starting to show declines as well.

3. With the reduction in revenue that physicians are seeing with their declining office visits, we can expect more doctors to approach us about an employment model. We must continue to tie these relationships to productivity and patient satisfaction structures that are justifiable and sustainable for the long term. We also need to continue to stress the need to partner with physicians in numerous other ways (like those identified trough our Physician Integrations task force) and come together to try and create win-win situations around high quality, low cost, and evidenced-based medical protocols and treatment plans.

4. We need to revitalize our focus on alternative/complementary medical services, which people will continue to seek once they discover and find them successful. Two of our Senior Vice Presidents are in charge of this activity, including the further identification of champion practitioners within our system. Fortunately, a good program has recently opened as part of the Sports Medicine and Wellness Center at CHRISTUS St. Vincent in Santa Fe, which can be used as a best practice to move forward in collaboration perhaps with our retail spa services or be created independently in our outpatient clinics.

5. We will need to continue to support other avenues to add additional funding to our revenues, which could include:
• The CHRISTUS Stehlin Foundation for Cancer Research
• Marketing some of our potential and already successful “adjacencies,” including TLRA, Revenue Cycle, Retail Services (including medical spas), convenient clinics, weekend and evening outpatient services on our acute care campuses, growth of our profitable non-acute services, etc.
• Garnering a clear understanding of how our international growth, which is less regulated, may provide more support for our U.S. ministries.

6. It is abundantly clear that the 5 strategic directions emanating from our intense Futures Task Force II work, driven by the overriding theme of having to become a high quality and low cost provider, are “right on” and position us well to respond to the changes and requirements brought about by health care reform.

It is important that we keep all of this information in mind as we continue to refine our system’s strategies in our acute, non-acute, and international divisions around our present and future thinking. Fortunately, the time we spend in future planning seems to be more and more valuable as we continue our Journey to Excellence.

It is reassuring to me, and I am hopeful to all of you, that we have much in place that, under Ernie Sadau’s future leadership, can be refined, intensified and accelerated to continue not only on our Journey to Excellence, but also to continue to strive to reach a goal that I put forth in my first speech in our first system leadership retreat in Houston in June of 1999: “To become one of the most excellent and most recognized health systems in the world.” Because of all of the efforts of the CHRISTUS family over the last 11 years, we are well on the way. The best is yet to come!