A Healthcare Landscape Roundtable with Three Top Physicians
As the healthcare landscape continues to evolve, the affluent population has an ever-greater role to play in shaping innovation and the quality of services offered by top institutions. We spoke with David Finn, MD, medical director of the Mass General Medical Group at Massachusetts General Hospital; Brian Cohen, MD, medical director of Pratt Diagnostic Center; and Shannon O’Kelley, chief operations officer, UCLA Hospital System to hear about their challenges and hopes for the future.
What sort of changes do you see coming for health care?
Dr. Brian Cohen:
A number of scientific breakthroughs are on the horizon. We will certainly see many more targeted therapies for cancer, and eventually we are going to see the fruits of the genomic revolution. The problem is these advances are likely to be quite expensive, and combined with unfavorable demographics—the aging of the baby boomers—healthcare costs are going to escalate at an even more rapid rate. One way of potentially dealing with that likelihood is through the Accountable Care Organization (ACO), a relatively new concept in organizing how care is delivered and coordinated. The Affordable Care Act created a program whereby ACOs that hold down Medicare costs can share in the savings obtained by delivering more efficient care. It remains to be seen how much cost saving this program achieves. I suspect there will have to be additional payment reform. We are already seeing a trend toward global payments—a healthcare organization is given a fixed sum to take care of a group of patients so that the organization bears the financial risk for high costs. There are different ways of monitoring this, but one way is to return to the concept of the primary care physician as a “care quarterback” who helps patients make educated choices.
We see a future where there are multiple ways to communicate with the hospital. We have spent an enormous amount of time building our IT infrastructure to support video teleconferencing and telehealth. Some of it could be as sophisticated as a home robot that can go from room to room, to something as simple as a Skype type of call to a navigator who can help patients with our system. We’ve also spent an enormous amount of effort building our electronic medical records so that we’re virtually tying all those components together and getting patients a little more involved in their own care. The new system is accessible by patients from their homes and by our faculty, whether they are in clinics, at home, or traveling.
How are you handling the costs related to implementing the new healthcare reforms?
Dr. David Finn:
We’re in a really challenging time right now, living in two worlds of reimbursement and of cost scrutiny. On the one hand, [there is] a movement toward population health management and trying to decrease unnecessary tests and procedures. At the same time, the way we’re compensated both as a system and individually is still a fee-for-service model [providers are paid for each service such as office visits, lab tests, etc.] and so we’re blending between these risk-based contracts, ACOs, and how you can care for your patients in the best way possible. Yet, if you do less of something that traditionally earns revenue, it improves one area and takes away another. The trend seems to be moving toward global payments and risk-based contracting and away from traditional fee-for-service. Trying to figure that out and to increase the utilization of services that generate high revenue, which allow academic medical centers to then cover the costs of treating the sickest of the sick and the low reimbursable problems like a burn unit that’s always open but not utilized unless there’s a need for it, is difficult.
We are trying to do a better job with the resources we have—getting better pricing on our supplies, focusing on how are we utilizing our labor pool, or managing the staff we have so it doesn’t grow completely out of whack. Also finding revenue opportunities, whether it’s a programmatic change we need to add to a service or adding resources to a program that contributes to the bottom line to help us pay for expensive things. In the past—and the past is no guarantee of the future—our transplant programs have provided us with resources that allow us to continue our mission.
We specifically set up our concierge practice 10 years ago to help subsidize the traditional primary care practice.
That’s where self-pay patients, international patients, and executive health programs help the overall mission of the hospital.
Are hospitals actively seeking to attract self-paying patients?
We have an international population that is self-pay and we are starting to see a lot more patients who are looking at what they’d have to spend in their deductible gap and what, say, the cost of a radiology exam would be if they paid cash instead of putting it through insurance.
That said, what role can the affluent population play in transforming health care?
When we set up our concierge practice, the main goal was to be profitable to help subsidize the other practice, but we also hoped it might help with philanthropy.
There is an increasingly interested donor who wants to effect change on a larger scale and really affect the way the system runs—not just support whether we make the changes in individual practices: What we’re trying to do is make those changes happen—like pilots—innovative ways to deliver care whether it’s virtual medicine or other things we’ve discussed, and then study that, publish it, show that it works.
Often these captains of industry may be able to advise us or help us navigate these turbulent waters to move forward. We benefit from relationships with these folks who have such a breadth and depth of business experience.
Over time philanthropy will play an increasingly large role in allowing hospitals to innovate, improve, and fund services as traditional resources dry up, even on the research side with National Institutes of Health funding being cut, and on the operations side with potential cuts in reimbursements. You can’t rely on philanthropy to keep the lights on, but it can allow institutions to improve health care for everybody.
As hospitals face a flood of new patients and decreased reimbursements, what steps are they taking?
We’re already running at 100 percent occupancy and our challenges are to better utilize the resources we have. How are we making up for the revenue? By using our facilities more effectively, we’re able to increase throughput.
Our approach is through care redesign, from a patient-centered medical home/medical neighborhood on the outpatient side, to improving access and efficiency on the in-patient side. We are changing the model of care to a more team-based approach with nurses, nurse practitioners, case managers, and social workers.
It’s no longer just about the bricks and mortar of the hospital; it’s not even about the clinic. How can we keep you healthy and out of both the clinic and the in-patient side? We’re doing a lot with our population management in telehealth, wireless devices to weigh and test glucose levels and those kinds of things, so that we do a better job of managing patient care outside of traditional health care.
That’s really a two-part question: What are we doing to accommodate patients? And what are we doing to make up for reduced reimbursements? Certainly, we’re trying to increase our staffing of primary care in the traditional practice. I also think the coordination of care is important, especially with sick people seeing multiple specialists when they get admitted, and the coordination of the out-patient experience is really important in making sure things are done efficiently, and reducing emergency room visits.
Dr. Cohen said it well: We should be focusing on care coordination. I’m not sure how well people fare if they don’t have someone inside who can provide that help up front to make sure it is truly coordinated care.
Sometimes it’s the low-tech solutions that work. Patients need access to the office, people to get in touch with and coordinate things for them.
What can be learned from developing first class services that can be applied to the rest of the hospital?
I’ve got an example: We have a board member who was identified as one of the top 20 inventors of the 20th century by Forbes. He had seen a report
on CNN with Lou Dobbs about an injured soldier who was horribly disfigured. Our board member was incredibly moved by the piece, so he put up a million of his own coin and asked us what we could do to help out. With his $1 million, and now we’re at $22 million, we’ve treated 100 service men and women from Iraq and Afghanistan, rebuilt their faces and their lives and created pilot traumatic brain injury and post traumatic stress disorder programs. This is a program m any VIP would love. For these wounded warriors, we coordinate flights. We pick them up at the airplane door and set them up at a suite at the hospital’s hotel. They jump to the front of the line. All this is possible because we had the fund development that allowed us to remove the barriers to providing perfect care. We created a first-class process for our wounded veterans that has shown the organization this is the way every patient should be treated. ✦