In recent posts, I’ve addressed the high cost of health care often associated with lesser quality when overuse or misuse of treatment and procedures are undertaken and when more emphasis is placed on treatment instead of prevention.
Clearly, another reason for these costly and often ineffective practices is that some older physicians may not be using the important tools associated with physical diagnosis, and some younger physicians may not be learning them.
When I was in medical school over 40 years ago, much time was spent on learning and then relying on four processes to make a diagnosis of our patient:
1. Inspection – Look at the patient and tell me what you see and what you think it indicates. Is the skin pale? It could indicate anemia. Yellow? Liver disease. Puffy? Hyperthyroidism.
2. Palpation (putting your hands on the body) – Do you feel breast mass, thyroid nodule, hernia, abdominal mass or abdominal aneurysm?
3. Percussion (beating on the chest & abdomen with a two-finger/drum stick technique) – Have you identified a solid lung lesion, or air or fluid in the pleural or abdominal cavity?
4. Auscultation (listening with a stethoscope to the heart, lung and bowel sounds) – Do you hear pneumonia, mitral valve disease, aortic regurgitation, or an obstructed, non-functioning bowel?
In addition, smell and a good history can be added to the four tools described above as inexpensive but often reliable adjuncts to reach the right diagnosis. I quickly learned that you can smell a pseudomonas infection on a burn patient, and that a person with acute appendicitis is never hungry.
These are important tools that cost little or nothing, but could focus the diagnosis with fewer lab and radiological tests. Unfortunately, however, the first line of approach by many providers as they begin the diagnostic journey is to start with an MRI or the CAT scan. And because we have far too many of these machines in the U.S., they, too, are overused.
I worry that the skills of physical diagnosis are rapidly being forgotten, and I worry more that if we do not enhance their uses in the future, the costs of health care may never decline.
Wednesday, July 15, 2009
Wednesday, July 8, 2009
Why More is not Necessarily Better
In a recent post, I addressed the problems associated with the overuse of medical procedures and studies made available by less invasive and safer technology.
Clearly, these are cases where more treatment is not better treatment. There are numerous examples proving that the focus on more medicines, procedures, lab studies, etc. as part of the treatment plan to control a disease rather than a strong emphasis on prevention to create wellness and health substantiate my belief that more is not necessarily better, but in fact is often far worse.
Although there are many scenarios that could be described to support this hypothesis, the most obvious are smoking, obesity and excessive drug and alcohol use.
Although we have known for years that smoking leads to disorders ranging from mild shortness of breath to virulent emphysema and lung cancer, we continue to provide misaligned incentives that do not inspire true change, as reimbursement is still provided for the treatment of the diseases rather than rewarded for removing the cause. If working with a patient on smoking cessation therapies including medication support was reimbursed at even 10 percent of what a cancer treatment plan costs, I am sure there would be significantly less smokers in the world, particularly if the patient and provider were both reimbursed an additional amount of money for every year the patient continues to not smoke.
We are also all familiar with the myriad illnesses that are caused or exacerbated by obesity, the number one health malady in the world. (I’m sure many of you heard of a study by the Trust for America's Health and the Robert Wood Johnson Foundation last week that reported that in 31 states, more than one in four adults are obese.) But rather than seriously encouraging both the patient and provider to focus on fixing an obesity problem, we provide more and more medicines and therapies to treat the resultant pedal edema, congestive heart failure and uncontrollable diabetes. We use more and more supply and labor, spending more and more money with little benefit. Again, what if the rewards for removing the cause were greater than those for stabilizing the resulting chronic disease?
Trauma, which was the leading cause of death in children 7-years-old and younger 25 years ago to the leading cause of death in people 52 years and younger today. I believe this statistic will reach 60 years by 2020. Trauma care is among the most complex and expensive to provide, and is often poorly reimbursed. We know that drug and alcohol usage accounts for the majority of traumatic events we treat in our Emergency Departments. Again, if some of the resources we applied to each trauma victim could be shifted to alcohol and drug prevention programs (which are much less costly), and like smoking, rewarded annually if relapses to do not occur, would we not have a better, less traumatic world in which to live?!
Yes, these are clear examples where we apply more and more of our resources daily which have no long-term benefit. To be successful, health care reform must realign incentives so that “less” at times will be embraced as better!
Clearly, these are cases where more treatment is not better treatment. There are numerous examples proving that the focus on more medicines, procedures, lab studies, etc. as part of the treatment plan to control a disease rather than a strong emphasis on prevention to create wellness and health substantiate my belief that more is not necessarily better, but in fact is often far worse.
Although there are many scenarios that could be described to support this hypothesis, the most obvious are smoking, obesity and excessive drug and alcohol use.
Although we have known for years that smoking leads to disorders ranging from mild shortness of breath to virulent emphysema and lung cancer, we continue to provide misaligned incentives that do not inspire true change, as reimbursement is still provided for the treatment of the diseases rather than rewarded for removing the cause. If working with a patient on smoking cessation therapies including medication support was reimbursed at even 10 percent of what a cancer treatment plan costs, I am sure there would be significantly less smokers in the world, particularly if the patient and provider were both reimbursed an additional amount of money for every year the patient continues to not smoke.
We are also all familiar with the myriad illnesses that are caused or exacerbated by obesity, the number one health malady in the world. (I’m sure many of you heard of a study by the Trust for America's Health and the Robert Wood Johnson Foundation last week that reported that in 31 states, more than one in four adults are obese.) But rather than seriously encouraging both the patient and provider to focus on fixing an obesity problem, we provide more and more medicines and therapies to treat the resultant pedal edema, congestive heart failure and uncontrollable diabetes. We use more and more supply and labor, spending more and more money with little benefit. Again, what if the rewards for removing the cause were greater than those for stabilizing the resulting chronic disease?
Trauma, which was the leading cause of death in children 7-years-old and younger 25 years ago to the leading cause of death in people 52 years and younger today. I believe this statistic will reach 60 years by 2020. Trauma care is among the most complex and expensive to provide, and is often poorly reimbursed. We know that drug and alcohol usage accounts for the majority of traumatic events we treat in our Emergency Departments. Again, if some of the resources we applied to each trauma victim could be shifted to alcohol and drug prevention programs (which are much less costly), and like smoking, rewarded annually if relapses to do not occur, would we not have a better, less traumatic world in which to live?!
Yes, these are clear examples where we apply more and more of our resources daily which have no long-term benefit. To be successful, health care reform must realign incentives so that “less” at times will be embraced as better!
Wednesday, July 1, 2009
The Dark Side of Technology
If I was forced to pick the most important driver of the improvement in the quality of health care in the U.S. in the last 40 years, it would be the advances we’ve seen in technology. Clearly, these advances have created much safer procedures and processes for patients and their families, many less-intensive and less complicated techniques for physicians and their teams and significant reduction in poor clinical outcomes.
Some of the more obvious examples of these improvements include:
•Better eye sutures so cataract surgery can be performed in 10- 20 minutes as an outpatient procedure as compared to the three-week mainly bedfast hospital stay with sand bags placed on both sides of the patient’s neck to minimize movement. A major complication of that kind of surgery and recovery included strokes in elderly patients.
•Use of laparoscopic surgery for gallbladder removal resulting in a short outpatient procedure and return to work and normal activities in four to seven days. This compares to a week-long hospital stay after an open right subcostal incision procedure, four days of which the patient had severe pain and nausea with the inability to return to work for four to six weeks.
• Proctoscopies done with a hard metal scope, which had to be carried out only by surgeons because 1 in 1,000 cases resulted in a perforated bowel. Now these bowel examinations are done with flexible scopes with little chance of a significant complication.
• Arteriograms done through the femoral artery as compared to those done through the carotid artery, causing numerous vascular compromise incidents.
Based on these few examples—and I believe there are many more--I have always said the “good old days” were not so good. Clearly, technological advances have created much brighter and better days from many perspectives. But, unfortunately, there is a dark side to technology.
As the equipment became safer to use, the ability for more providers to do more procedures in less acute locations has occurred. Procedures once done only in a hospital can now be done in doctors’ offices, ambulatory surgery centers, specialty hospitals and even convenient clinics. This increased availability in multiple settings by multiple providers has resulted in an overuse of these procedures often driven by revenue enhancement (What’s best for me?) vs. quality care (What’s best for the patient?). In addition, many of the highly-reimbursed procedures have been moved out of hospitals, resulting in extremely low income levels and making the survival of some hospitals almost impossible.
Because of this knowledge, Obama and Congress, who are driving health care reform, believe if the revenue overuse was replaced with evidence-based quality guidelines for use, billions of dollars could be saved while simultaneously improving quality. They are right. The question is, do we as health care leaders have what it takes to eliminate this dark side of technology and replace it with only the best use of this technology for the right patient and the right time at the right cost?
Some of the more obvious examples of these improvements include:
•Better eye sutures so cataract surgery can be performed in 10- 20 minutes as an outpatient procedure as compared to the three-week mainly bedfast hospital stay with sand bags placed on both sides of the patient’s neck to minimize movement. A major complication of that kind of surgery and recovery included strokes in elderly patients.
•Use of laparoscopic surgery for gallbladder removal resulting in a short outpatient procedure and return to work and normal activities in four to seven days. This compares to a week-long hospital stay after an open right subcostal incision procedure, four days of which the patient had severe pain and nausea with the inability to return to work for four to six weeks.
• Proctoscopies done with a hard metal scope, which had to be carried out only by surgeons because 1 in 1,000 cases resulted in a perforated bowel. Now these bowel examinations are done with flexible scopes with little chance of a significant complication.
• Arteriograms done through the femoral artery as compared to those done through the carotid artery, causing numerous vascular compromise incidents.
Based on these few examples—and I believe there are many more--I have always said the “good old days” were not so good. Clearly, technological advances have created much brighter and better days from many perspectives. But, unfortunately, there is a dark side to technology.
As the equipment became safer to use, the ability for more providers to do more procedures in less acute locations has occurred. Procedures once done only in a hospital can now be done in doctors’ offices, ambulatory surgery centers, specialty hospitals and even convenient clinics. This increased availability in multiple settings by multiple providers has resulted in an overuse of these procedures often driven by revenue enhancement (What’s best for me?) vs. quality care (What’s best for the patient?). In addition, many of the highly-reimbursed procedures have been moved out of hospitals, resulting in extremely low income levels and making the survival of some hospitals almost impossible.
Because of this knowledge, Obama and Congress, who are driving health care reform, believe if the revenue overuse was replaced with evidence-based quality guidelines for use, billions of dollars could be saved while simultaneously improving quality. They are right. The question is, do we as health care leaders have what it takes to eliminate this dark side of technology and replace it with only the best use of this technology for the right patient and the right time at the right cost?
Tuesday, June 30, 2009
CHRISTUS Health on the Right Journey as Health Care Reform Initiatives Accelerate
Clearly, the CHRISTUS Health goal to continue our journey to become one of the highest quality and lowest cost providers both in the U.S. and internationally appears to be the key to success for the for the minds of those driving health care reform, including Sen. Kennedy and President Obama.
The proposed plans emanating from the White House and Congress have several key strategies in common, including:
- All persons will have health insurance
- Those who can afford such will buy private insurance
- Federal and state governments will approve waivers and subsidized insurance for the poor
- Large employers will be required to continue to support health insurance for their employees
- Small employers will be subsidized to support their employees
- Providers will be paid parallel to their quality and service metrics
- Utilizing evidenced-based medicine protocols to minimize overuse of technical studies and procedures will be rewarded
- As the poor and underserved are covered by insurance, the DSH payments will be reduced
- Pharmaceutical companies will be forced to reduce prices
Clearly, the American Medical Association, American Hospital Association and Catholic Health Association are advocating for no reductions in payments until a feasible reform plan is developed and implemented. Unfortunately, as CHRISTUS Health leaders have been saying both to our internal and external audiences, there is no more money in the treasury, bad debt in health care is increasing and costs must be reduced immediately as fast as possible while the health care reform plans are being debated. Therefore, our leadership team has growing concerns about the Associations’ pleas for more money. Our approach is to offer concrete solutions which we have evolved over our first decade of CHRISTUS Health to increase our clinical and service quality, reduce our costs by enhancing our business literacy, while maintaining our leadership role in providing care for the poor, both in the U.S. and Mexico – our Journey to Excellence.
Clearly, many businesses, organizations and individuals have their eye on health care. Because we have had numerous discussions about the Wal-Mart organizations as we have opened our convenience clinics in partnership with them, I thought it would be appropriate to share a recent editorial written by Mike Duke, the president of Wal-Mart.
You can access the article at http://thehill.com/op-eds/wal-marts-eye-on-healthcare-2009-06-15.html.
As always, I hope you find the article to be informative and enlightening.
Wednesday, June 24, 2009
New Financial Reality Accelerates our Journey to Excellence
For CHRISTUS Health, the global economic crisis has prompted the need to proactively accelerate our Journey to Excellence, striving to more rapidly improve our clinical and service quality while reducing costs. Driven by our Futures Task Force II recommendations as they are incorporated into our three-year rolling strategic planning process, we know our future strategic initiatives must be affordable, given the new financial reality. Hence we have enhanced our planning process with use of two new tools for our acute, non-acute and international ministries. These are an operational algorithm and Strategic Portfolio Analysis (SPA).
In addition, we know that organizational risk must be managed more intensely and therefore have developed and implemented a comprehensive, system-wide Enterprise Risk Management program. We have prioritized 19 high-risk areas, and are systematically developing action plans to mitigate these risks as we move into the future.
Additionally, to become more business literate as we continue our Journey to Excellence, we must continue to enhance our business development process, creating a more viable and stable financial plan going forward. To do this, we are securing--under the best possible terms--our debt structures and intentionally slowing our capital appetite in comparison to the expenditures we approved in our first decade of existence.
And finally, because of the goals embedded in our four directions to excellence, guided by our balanced scorecard approach, we continue to see advances in our clinical and service quality metrics while our labor and supply cost have showed significant declines.
As leader of CHRISTUS Health, I can tell you that we would have done all of this regardless of the recent financial crisis. But there is no doubt that these financial challenges have intensified our focus and accelerated our progress on this journey. Luckily, this means we are well-positioned to continue fulfilling our mission far into the future.
In addition, we know that organizational risk must be managed more intensely and therefore have developed and implemented a comprehensive, system-wide Enterprise Risk Management program. We have prioritized 19 high-risk areas, and are systematically developing action plans to mitigate these risks as we move into the future.
Additionally, to become more business literate as we continue our Journey to Excellence, we must continue to enhance our business development process, creating a more viable and stable financial plan going forward. To do this, we are securing--under the best possible terms--our debt structures and intentionally slowing our capital appetite in comparison to the expenditures we approved in our first decade of existence.
And finally, because of the goals embedded in our four directions to excellence, guided by our balanced scorecard approach, we continue to see advances in our clinical and service quality metrics while our labor and supply cost have showed significant declines.
As leader of CHRISTUS Health, I can tell you that we would have done all of this regardless of the recent financial crisis. But there is no doubt that these financial challenges have intensified our focus and accelerated our progress on this journey. Luckily, this means we are well-positioned to continue fulfilling our mission far into the future.
Wednesday, June 10, 2009
Verification of our strategies and focus
We recently reviewed data on where health system revenue is being generated and a chart showing the increasing shortfall in payments relative to costs for Medicare and Medicaid. This reaffirmed for CHRISTUS Health that our strategy to transition our portfolio to become one-third acute care in the U.S., one-third non-acute care in the U.S. and one-third international, is undoubtedly the right direction.
In addition, because we recognize that our ability to increase our revenue from “same-shore” business is virtually impossible, particularly from our Medicare and Medicaid books of business, our focus on becoming one of the high quality/low cost providers is clearly the best strategy to guarantee long-term sustainability for our health and wellness ministry.
Clearly, a major task for hospitals and health systems is striving to balance their revenue with their costs, an increasingly complicated task because of such factors as the continuing shift to outpatient care (which CHRISTUS has been predicting and planning for) and the expanding payment shortfall relative to costs for Medicare and Medicaid. In addition, CHRISTUS Health has many facilities and programs in Louisiana and Texas, two of the states with the lowest Medicaid payments. These findings are verified in the charts depicted below:
As we continue our Journey to Excellence, attaining our goal to be one of the highest quality, low-cost health and wellness providers appears to be within our reach.
In addition, because we recognize that our ability to increase our revenue from “same-shore” business is virtually impossible, particularly from our Medicare and Medicaid books of business, our focus on becoming one of the high quality/low cost providers is clearly the best strategy to guarantee long-term sustainability for our health and wellness ministry.
Clearly, a major task for hospitals and health systems is striving to balance their revenue with their costs, an increasingly complicated task because of such factors as the continuing shift to outpatient care (which CHRISTUS has been predicting and planning for) and the expanding payment shortfall relative to costs for Medicare and Medicaid. In addition, CHRISTUS Health has many facilities and programs in Louisiana and Texas, two of the states with the lowest Medicaid payments. These findings are verified in the charts depicted below:
As we continue our Journey to Excellence, attaining our goal to be one of the highest quality, low-cost health and wellness providers appears to be within our reach.
Wednesday, June 3, 2009
Creating Value During this Economic Crisis
As July 1, 2009 arrives and marks the beginning of our new fiscal year, the Senior Leadership Team of CHRISTUS Health has been engaged in deliberate and thoughtful discussions on the services and related expenses we need to provide going forward. As a result, significant expense reductions are planned and are being communicated in several phases.
In addition, the team has been diligently reducing the CHRISTUS global corporate expenses throughout the FY09 fiscal year, resulting in actual expenses below budget of $8 million, plus an additional reduction of $6 million for Information Management services. This, of course, has provided a great starting point for the additional reductions in the coming months.
How have we decided which programs to reduce? Contrary to doing across-the-board cuts of the same percentage for all, the team reviewed the past budget, analyzed the value of projects and services provided to our regions and business units and considered advice provided by a Corporate Services Task Force as well as strategies and directions from our system governance board and Futures Task Force II.
This recent journey to enhance our position as a high quality/low cost provider was reflected in a recent article by the Korn/Ferry Institute entitled, “ ‘Fast Consolidation’: Creating Value in a Brutal Economy.” In it, they indicated that, unfortunately, most organizational leadership tries to promote fairness by using a “peanut butter” approach to implementation which requires all departments equal pain. We purposely avoided such by following four action plans that were articulated by the authors:
1. Initiatives prioritization and rationalization — taking a hard look at all the existing so-called “strategic initiatives” and stopping the ones that don’t unequivocally support the current strategy will create the expected pay-off.
2. Centralization and standardization of back-office functions — once the downsizing takes place, non-client facing functions should be the first candidates for centralization. Since process standardization can create short-term costs, leaders should have visibility over the cost-benefits analysis of standardizing processes.
3. Redefinition of roles and responsibilities — very often companies go through reductions-in-force but do not take the immediate necessary steps to redefine key roles and responsibilities across the enterprise. This job can’t be fully delegated to HR or organization design functions (even though HR should partner with business unit and functional leaders to make it happen), since it should be a leadership-led exercise.
In fact, once roles and responsibilities principles, criteria and guidelines are clear, the new organization blueprint and leadership selection should be relatively straightforward.
4. Clear and timely communication highlighting the path forward — the remaining workforce should receive clear and timely communication regarding the rationale for the actions taken, the path forward and the role that they are expected to play in the new organization. If not invited to be leaders as opposed to followers, the remaining workforce will likely take a passive and reactive approach. They need to clearly understand what commitments the leadership team can make to them but also what is expected from them in the times ahead.
As I have been repeatedly saying both to our internal and external audiences, CHRISTUS Health sees the global economic crisis as a rainbow in the clouds. It has given all of our regions and business units in our acute, non-acute and international divisions, as well as global corporate services, the opportunity to revisit our operating models, to as effectively as possible assess the value of each program and service we provide, and then eliminate or redesign what is maintained so we continue to strengthen our health and wellness ministries to assure long-term success as we continue our Journey to Excellence.
In addition, the team has been diligently reducing the CHRISTUS global corporate expenses throughout the FY09 fiscal year, resulting in actual expenses below budget of $8 million, plus an additional reduction of $6 million for Information Management services. This, of course, has provided a great starting point for the additional reductions in the coming months.
How have we decided which programs to reduce? Contrary to doing across-the-board cuts of the same percentage for all, the team reviewed the past budget, analyzed the value of projects and services provided to our regions and business units and considered advice provided by a Corporate Services Task Force as well as strategies and directions from our system governance board and Futures Task Force II.
This recent journey to enhance our position as a high quality/low cost provider was reflected in a recent article by the Korn/Ferry Institute entitled, “ ‘Fast Consolidation’: Creating Value in a Brutal Economy.” In it, they indicated that, unfortunately, most organizational leadership tries to promote fairness by using a “peanut butter” approach to implementation which requires all departments equal pain. We purposely avoided such by following four action plans that were articulated by the authors:
1. Initiatives prioritization and rationalization — taking a hard look at all the existing so-called “strategic initiatives” and stopping the ones that don’t unequivocally support the current strategy will create the expected pay-off.
2. Centralization and standardization of back-office functions — once the downsizing takes place, non-client facing functions should be the first candidates for centralization. Since process standardization can create short-term costs, leaders should have visibility over the cost-benefits analysis of standardizing processes.
3. Redefinition of roles and responsibilities — very often companies go through reductions-in-force but do not take the immediate necessary steps to redefine key roles and responsibilities across the enterprise. This job can’t be fully delegated to HR or organization design functions (even though HR should partner with business unit and functional leaders to make it happen), since it should be a leadership-led exercise.
In fact, once roles and responsibilities principles, criteria and guidelines are clear, the new organization blueprint and leadership selection should be relatively straightforward.
4. Clear and timely communication highlighting the path forward — the remaining workforce should receive clear and timely communication regarding the rationale for the actions taken, the path forward and the role that they are expected to play in the new organization. If not invited to be leaders as opposed to followers, the remaining workforce will likely take a passive and reactive approach. They need to clearly understand what commitments the leadership team can make to them but also what is expected from them in the times ahead.
As I have been repeatedly saying both to our internal and external audiences, CHRISTUS Health sees the global economic crisis as a rainbow in the clouds. It has given all of our regions and business units in our acute, non-acute and international divisions, as well as global corporate services, the opportunity to revisit our operating models, to as effectively as possible assess the value of each program and service we provide, and then eliminate or redesign what is maintained so we continue to strengthen our health and wellness ministries to assure long-term success as we continue our Journey to Excellence.
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