Going into Drydock

I am going to take a bit of a sabbatical from this blog.  I am spending more time working with companies in the patient/provider communication space, and find my inspiration is aligning more around that subject. My husband and I contribute to a blog, “Leave a Message…”, where we share our thoughts about tips, trends, best (and worst) practices on how patients and healthcare providers interact, whether it is via phone, social media, the internet, patient portals, signal flags (just kidding)  or any other communication medium.

Healthcare is rapidly changing with tricky seas ahead. Some day, I may decide once again, to put this old boat back in the water   But til then I wish my readers smooth sailing and give a honk and a waive when you pass by.

Janet

Convenience Causes the Lines to Blur

No matter what your profession, during social events talk turns to topics that are related to what you do.   Lawyers are often engaged in conversation regarding legal topics, clergy often get cornered on religious topics, and nurses and physicians are often shanghaied into a conversation that has to do with someone’s health history.  Since my family knows that I am a recent Healthcare management MBA, the topic I often encounter is the business of healthcare, or why does it cost so much.   One such conversation occurred after Thanksgiving dinner, between my uncle, a retired businessman who survived a major health issue, my aunt who is a physician who works for the VA, and my brother who is a government employee.  The discussion had many interesting points, (VA clinics vs. Medicare vs. Private Coverage, what people pay in vs. benefits received), but what struck me as the “aha” moment was when we started comparing notes on where we all got our flu shots.   Gone are the days when you waited to make an appointment to get the vaccination from your doctor.  Nowadays, you are just as likely to get them from a pharmacist or NP at a drugstore, as you are from your GP or internist.   Cost is not a big driving factor, if one is covered by Medicare or private insurance (as we all were), the out of pocket cost is about the same.   The driver of our choices of where to go, seemed to be convenience.

The Thanksgiving conversation seemed to mirror the findings of a Rand report that was released earlier in the week.  A press release for the study noted a 10 fold increase in retail clinic usage between 2007 and 2009.  (If the numbers ran to 2011 I’m sure there would be a greater increase). The RAND team used data from a commercially-insured population of 13.3 million lives. Of that number, close to a third (3.8 million enrollees) made at least one clinic visit between 2007 and 2009.

According to the press release, “The strongest predictor of retail clinic use was proximity. Other key predictors are gender (females were more likely to visit clinics than males), age (retail clinic patients tended to be between the ages of 18 and 44; those over 65 were excluded from the study), higher income (those from zip codes with median incomes of more than $59,000 were more likely to use retail clinics than lower income groups), and good health (those with a chronic health complaint were less likely to use retail clinics).”

“It appears that those with a higher income place more value on their time, and will use clinics for convenience if they have a simple health issue such as a sore throat or earache,” said Dr. Ateev Mehrotra, the study’s senior author and an investigator at RAND and the University of Pittsburgh.”

The trend for healthcare provisioning in alternate venues will only increase as more businesses realize the synergy of being in the clinical space. If the Rand report is correct, it shows those who value time will opt for convenience (retail clinics close to home), leaving sicker/poorer patients to use the higher priced options (clinics and E/R’s).  While Wal-Mart back peddled on a rumored RFI to create a low cost integrated primary platform, (see here) make no mistake, it is looking at ways to increase its reach in the healthcare.  According to a recent report in FierceMobile Wal-Mart (like Walgreens and others) is exploring many options, including mHealth applications.  As these new players, with their deep pockets and consumer expertise, enter the clinical space, traditional players will need to adapt to keep profitable market share.   Like the dinosaurs, size will not matter.  Those who survive will understand the cultural shifts that have to start now, so that their organizations will be ready when this trend reaches critical mass. Don’t ignore the lesson of the independent drugstores. They used to be plentiful.  But when was the last time you saw one of them?

Another example of educated patients improving their outcome…

Regular readers of my blog, knows that improved outcomes via patient adherence is an ongoing interest of mine.   Earlier this month, the New York Times had a blogpost about a program at UCSF where nurse educators worked with heart failure patients to reduce readmissions.

How the program worked was very simple.   A coordinator spends at least one hour explaining the patient’s condition to the patient and his or her family, and preparing them to manage the patient’s condition outside the hospital setting.   The coordinator asks questions about the patient’s diet and gives healthy alternatives.  They teach caregivers how look for troubling symptoms, and about the medications the patient is on.   Patients and caregivers develop an ongoing relationship with the program with emails, phone calls and home visits.  There is even coaching on how to interact with other health care providers.

While the program is not cheap, it has a great ROI.   It began with a $575,000 grant and UCSF continues to fund it.   However, since the program began three years ago, the hospital’s heart failure readmission rate has dropped by 30 percent and the hospital estimates the program has saved Medicare at least $1 million a year.

It’s another example of educated patients (and caregivers) improving the quality of their lives, and reducing the burden on our healthcare system. It’s a no brainer, and yet these programs are few and far between.   We need to figure out ways to fund and support more of these programs.   It’s in everyone’s best interest.

 

You have to give them carrots and sticks….

Hospitals are dammed if they do, dammed if they don’t.   The federal government is pushing them to reduce 30 day readmissions to lessen the Medicare spend.  However, when hospitals comply, they get bit.   An example taken from a recent post to the Bloomberg News website.

The Mount Sinai (NY) experience may be instructive. From September 2010 to May 2011, the hospital’s Medicare revenue rose only 2 percent over the previous year — in part because the number of inpatient cases fell. Why was that? One important reason was that the number of patients readmitted to the hospital within 30 days of discharge was 5 percent less than what it had been the previous year.

The post continues;

Reimbursement from Medicare is still primarily based on how many services hospitals perform rather than on how well they care for patients, so hospitals are often financially penalized for improving value and quality. The Mount Sinai program to reduce readmissions, for example, is costly for the hospital both because of the extra expense of running it and because fewer readmissions means less revenue. Ken Davis, the president and chief executive officer of Mount Sinai, says the hospital won’t be able to afford continuing the successful program if the financial incentives remain so skewed against it.

Granted the author, Peter Orszag has a political agenda with his views, having been a President Obama’s former director of the Office of Management and Budget.   However, the only reason Mt Sinai is even looking at reducing 30 day admissions is because they are no getting paid for it.  However if at the end of the day, the math doesn’t work, look for it and other hospitals to question their readmission reduction programs.

The Intersection of Cost, Quality, and Patient Satisfaction

Now that we are in the dog days of summer, I have some time to catch up on some of my backlog.  There were two items today that caught my attention.

John Goodman (the policy analyst, not the actor), has been writing in his blog about the relationship between the underlying cost of care, wait times, amenities and quality.  In an April 27 blog post he observes that when costs are transparent, and consumers have skin in the game, providers will compete on price and quality to garner business.  In a  follow up post dated June 29th , he writes about the inverse, what happens when third-party payors obscure the true cost of care.  Goodman notes that when patients do not make choices based on price, they will make choices based on time, quality or amenities.  And since quality information is the hardest to gather, patients will make use the markers that are easier to see, time to access, and amenities.  Goodman observes in markets where there is a undersupply of services, hospitals wanting to cater to patient satisfaction might not be as quick to improve quality if it means grumbling patients have to wait longer for services.  And in markets that have oversupply, many facilities go the less expensive route and compete on amenities, rather than instituting the more expensive changes that bring up quality levels. Goodman says it best “Some of the literature on hospital economics suggests that quality improvement is quite expensive, and that dollar-for-dollar amenity improvements will increase hospital revenues by more than quality improvement. This is coupled with surveys that find patients more sensitive to amenity changes than to quality changes. (Of course, this latter finding may only reflect the fact that hospitals aren’t really trying to communicate quality information.)”

A perfect intersection of what Goodman is talking about is a new service called InQuickER.  It is a website that allows patients to schedule their ER visits with participating hospitals.   My first reaction was “Are you kidding?”, but after I counted to 10, I started to smile.

The concept is brilliant.  Emergent cases are notified to go to the nearest ER. Non-emergent cases are slotted in predictable times. Patients love that they are not sitting around the ED waiting room.  Staff likes it because it allows load balancing of non-critical cases.  Participating hospitals like it as they are able to offer a low-cost perk, and differentiator.   There is a fee to use it, which looks like $4.99 for an urgent care center appointment, $9.99 for an ED appointment.

However I have to ask, if the patient is paying the true cost instead of the co-pay, would they be going to the ED for non-critical care in the first place?   Or would they go to a physician’s office (or retail clinic) instead?

Hospital Compare

So instead of doing my reading for my project management class (only 5 more weeks of school), I was on HootSuite seeing what was going on in my Twitter world.  On my business account @janetlsameh I follow 275+ folks from all over the world. In a 30 minute period I can see tweets that  range from complaints about local barrista’s to comments on macroeconomics trends.  Most of the commentators I follow touch healthcare, so the majority of  what I see falls within that realm.

Two unrelated tweets caught my eye today.  The first was from Atul Gawande linking to an blog post from the Atlantic.  The article talked about Todd Park.  For those who do not know about Todd, he is the chief technology officer of HHS, and has the idea to harness the power of  HHS data to spur innovations that improve the nation’s health and welfare.   One of the new tools that uses the HHS data, is  Hospital Compare, a website that contains detailed quality and patient satisfaction information from hospitals across the country.  The second tweet was from Mark Harmel, linking to a blog post from e-Patient Dave (Dave deBronkart) where Dave shares his experience of using Hospital Compare to choose which hospital to take his wife to when she had a foot problem.  Dave talks about how instead of automatically going to their default hospital an hour away, the deBronkarts decided to use Health Compare to choose a much closer hospital.   And it worked out fine.

e-Patient Dave’s experience shows that Todd Park’s vision is starting to work.  Granted Dave is a noted patient advocate and a VERY educated consumer of healthcare, but as more applications like Health Compare start to become accessible to consumers, it will begin to impact choices that patients make. e-Patient Dave’s case would not be a lot of revenue for the default hospital, but it impacted the relationship the deBronkarts had with it.   Instead of always going to one hospital, the deBronkarts, now have options.

Thanks to Todd Park, the data is out there. Hospital and health systems who don’t understand the impact that having the HHS data in an online patient friendly platform need to get up to speed quick.  Consumers are used to going to sites like Yelp or travel sites to see feedback on hotels, restaurants and the like.  Once they learn there is a place they can compare quality data and patient satisfaction scores for their local hospitals, they will use that to make healthcare decisions as well.

A Suprising Disparity

Two of the more interesting people I follow are @edbennett who has a website, Found in Cache where he tracks hospital social media use, and @pharmaguy (John Mack), publisher of the website Pharma Marketing News.   Both sent me updates this weekend regarding the use of social media in the healthcare areas they follow, and the side by side comparison was very interesting.

According to Ed Bennett’s accounting: 1,188 Hospitals were using social media via the following chanels:

• 548 YouTube Channels
• 1018 Facebook pages
• 788 Twitter Accounts
• 458 LinkedIn Accounts
• 913 Four Square
• 137 Blogs

According to numbers John Mack compiled on a slide share presentation he posted, Pharma accounts for:

• 38 YouTube Channels
• 65 Facebook pages
• 70+ Twitter Accounts
• 37 Brand Sponsored Patient Communities
• 10 Blogs

I never would have thought hospitals would be ahead of Pharma in any marketing endevors, especially social media.  Yes, Pharma lives in a VERY regulated world regarding how they can communicate their brand message to patients. And Yes, one of the tenents of social media is transparency, something that pharmecutical companies are not always good at. However, I say that for as sophisticated as Pharma is about DTC, and other outreach tactics, they need to recognize they are missing the boat (no pun intended) on social media.   Banking and other regulated industries have figured out.  It is time for Pharma to get creative.

>Age Matters?

>According to a commentary written in journal Obstetrics & Gynecology by Sharon Phelan, a professor of obstetrics and gynecology at the University Of New Mexico Health Science Center School Of Medicine, the generational shift in attitudes regarding work/life balance is causing culture clashes in today’s hospitals.

While her perspective is OB-GYN, her observations carry over to other specialties.

The WSJ Health Blog has a discussion of her findings – an excerpt of the discussion follows:

Many older physicians — she includes herself in this group — have “tended to live our lives around our careers, with our families secondary,” Phelan tells the Health Blog. “The younger generation refuses to do that. They may have a more even-keeled approach to it or even believe that personal life takes priority over work life.” That means they’re more open to shift work and more likely to emphasize a team approach to care. (That attitude is not limited to younger women, she notes; men, too, are putting more emphasis on their family life.)


The clash comes from how this translates to “appropriate” care for patients, she says. “The risk is that the more senior folks think the newer folks don’t care and that they’re not professional, and look down on them,” she says. “Meantime some of the younger folks have lost respect for the older folks — they think they’re incredibly misdirected in their emphasis” on work above all else.

What is missing from this discussion is ownership. Most older physicians are in smaller private practices. The viability of their business and their economic livelihood are directly related to the relationship they build with their patients. Most younger physicians are employees of larger practices, or health systems. As employees, they have a different perspective on patient relationships. As physicians, they want to do what is best for the patient, but the incentive is often not be there for them to sacrifice their life outside of work.

Dr. Phelan is correct in identifying that there is a shift in the attitudes between older and younger providers. And yes, much of it is due to the younger generation’s attitudes of work/life balance. However there is more to it than just generational mind-sets. Roles and economic rewards enter into play as well.

>The recession may be succeeding where policy has not…

>From today’s WSJ:

“People just aren’t using health-care like they have,” said Wayne DeVeydt, WellPoint Inc.’s chief financial officer, in an interview Wednesday. “Utilization is lower than we expected, and it’s unusual.”

Others say that consumers are beginning to forgo elective procedures like knee replacements. “We have a very weak economy and it’s just a different environment for the elective parts of health care,” said Paul Ginsburg, a health economist who runs the Center for Studying Health System Change and has been analyzing health-company earnings. But “this could go beyond the recession. Being a less aggressive consumer of health care is here to stay.”

 Employees with employer sponsored health insurance, are paying more out of pocket, with larger co-pays and deductibles. And for those who were laid off, COBRA has run out or is too expensive. Basic economics state that when the price of a good goes up, demand decreases. This coupled with a growing trend of consumerism in healthcare means providers will have to work even harder for a patient’s dollar.

Should be interesting….

>Another reason not to like Mondays…

>In the 2010 Press Gainey Emergency Department Pulse Report, there is a lot of information regarding patient satisfaction and ED’s. However one of the more interesting pieces of information is timing of an ED visit.

From the report:

The first graph clearly shows that Monday has the lowest overall mean score for patient satisfaction with the average mean score rising steadily before reaching its pinnacle during the weekend.

The second graph drills deeper into this data by dividing scores into weekday versus weekend, as well as into six time periods throughout the day. Scores indicate that satisfaction is highest during the 7 a.m.-11 a.m. time period for both weekend and weekday. After 11 a.m., both weekend and and weekday scores decrease steadily through the 7 p.m.-11 p.m. period. At this point, the weekend scores decrease again for one more period, while the weekday scores increase slightly. From 11 p.m.-3 a.m. and 3 a.m.-7 a.m., both weekend and weekday scores increase sharply.


According to the Centers for Disease Control (http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf), in 62.9% of adult ED visits, the patient arrived after business hours. Despite this, Press Ganey consultants have noted that many organizations are staffed as if they were 9 a.m.-5 p.m., Monday through Friday operations. This could be one reason why weekdays between 3 p.m. and 3 a.m. are a weak spot.

(For a larger version of the graph and other information click here)