Rx for a Changing Healthcare Landscape
Many assume that the ability to pay for care insulates them from the challenges of navigating today’s healthcare system. Unfortunately, this is not the case. Access to the very best medical care frequently eludes even well-connected patients, who are often unaware that the care they receive falls short of their standards. With the approaching healthcare reform, demands on hospital resources will continue to increase, affecting both access to care and doctors’ capacity to deliver it, even for those with platinum insurance policies and significant financial resources. While Americans remain hopeful that the new legislation will lessen the financial burden on society and lead to a healthier populace overall, astute observers recognize that reform will likely result in long- and short-term economic and logistical hurdles. Insurance companies, struggling to maintain profit margins under the pressure of new legislation, will inevitably exercise more control than ever in medical decision making in an effort to trim costs. Moreover, physicians will need to focus not just on the health of the individual but also on the health of populations. These momentous shifts in the way medicine is managed and delivered require those of us who are committed to maintaining our health and, thus, our quality of life, to play a more proactive part in our personal healthcare equation, educating ourselves on disease prevention and the types of treatment of available. In effect, we must become connoisseurs of health.
Though insurance companies have limited power to push back on certain benefits, because they must meet the essential requirements of the Affordable Care Act (ACA), “they will more likely manage cost concerns through their premium pricing strategies for the respective types of plans offered,” says Patricia Brown, senior vice president of Managed Care and Population Health at Johns Hopkins Medicine and president of Johns Hopkins HealthCare LLC. She adds that insurers will also likely narrow their network of providers to exclude higher-priced physicians and systems, as UnitedHealthcare did in in November, when the company sent termination letters to doctors in its Medicare Advantage network. Brown also anticipates that insurers will exert greater control in determining which procedures and tests are necessary. “No doubt insurance companies will do what they can to continue to be a viable and necessary part of the healthcare financing system,” she says.
The financial underpinnings of healthcare financing form a delicate and complicated web—one that leaders of the best organizations are adept at unraveling. “Institutions are made up of myriad cross-subsidies,” says Massachusetts General Hospital (MGH) President Peter Slavin, MD. “We use margins that we generate in cardiac and cancer services to cross-subsidize mental health and obstetrics services. We use margins from well-insured patients to cross-subsidize the care of poorly insured or uninsured patients.” As cutbacks in federal funding, growth in Medicaid programs, and changes in payment structures under the ACA disrupt this careful arrangement, top hospitals will need to balance their spreadsheets by attracting people who are “well insured and potentially in a position to help us philanthropically as well, if we want to be able to continue to sustain the academics, community health missions, and excellence of places like Mass General,” says Dr. Slavin.
Cleveland Clinic—which bills itself as the world’s second-largest group practice, with facilities in Ohio, Florida, Nevada, Canada, Saudi Arabia, and Abu Dhabi—shares Dr. Slavin’s position. In fact, says Richard Lang, MD, MPH, department chair at Cleveland Clinic Executive Health, like any business, a hospital needs to consider the bottom line, and for Cleveland Clinic, MGH, and other top medical facilities, preserving financial viability means making cuts in some places and looking for new streams of revenue in others.
Fiscal concerns—and, specifically, the methods by which hospitals and physicians are reimbursed for care—behoove the healthcare industry to place greater emphasis on populations and disease prevention, rather than on individuals and disease treatment. Under the current model, a doctor gets reimbursed on a fee-for-service basis—that is, for every test he or she orders or procedure performed. The federal government and private insurance companies set the costs of procedures and tests, and decide what will be reimbursed based on specific criteria. Under the new model, insurers or the government will reimburse hospitals and doctors based on the number of patients they see. A fixed dollar amount is assigned per patient, shifting the focus toward prevention and reduced hospital stays. However, there is a risk that an individual’s time spent with a primary care physician will grow ever shorter as doctors try to see as many patients as need them, even as the predicted number of family physicians per capita begins to dwindle further.
A hedge against this potential scenario can be found in executive health programs. Operating to some degree outside of insurance constraints, these services address the whole health of a patient, from physical to mental, and assist them in achieving a work-life balance. Originally conceived 50 to 60 years ago by Fortune 500 companies seeking to protect their investments in their CEOs, such programs have now progressed beyond their corporate origins to provide comprehensive and convenient care for anyone who wants to pay out of pocket for the extra attention.
Executive health services are excellent tools for preventing illness, as they allow physicians to return to best practices. “What has happened in the evolution of executive health is we’re looking at what provides the greatest value to the individuals who come through our program,” says Cleveland Clinic’s Dr. Lang. “The value of any program is the quality of the advice patients are being given. It’s not the screening tests; it’s not any bells and whistles. It’s the quality of the interactions with the doctor and the mental health coach and the dietitian and the exercise physiologist to understand how it all fits together.”
These interactions comprise the preventive-care visit in most executive health programs, where the focus is on conducting a thorough examination of the individual’s overall physical and mental health. Yet, just as importantly, these programs offer patients the opportunity to forge long-term relationships with the leading institutions in the country. Patients enrolled in these programs have the advantage of being known both personally and medically by the institutions, ensuring that, should a serious medical condition develop, the institution’s staff has sufficient knowledge of the patient to diagnose and treat that condition more quickly and effectively than someone who is walking through the door for the first time.
“What makes an executive health program anywhere valuable is the time with a provider who’s ready to go through everything in someone’s history, assess his or her risk factors, and go forward from there,” says Bimal Ashar, MD, MBA, medical director of the Executive Health Program at Johns Hopkins Medicine. He compares his executive health practice to the traditional primary-care practice he maintains simultaneously, though he is keenly aware of the luxury of extra time with his patients the former allows him—time to acquaint himself with their medical and other concerns, their businesses, and the names of their children.
These details are important to providing the very best possible care, says Ben Ansell, MD, director of UCLA’s Comprehensive Health Program (CHP). “This is a dialogue,” he adds. “I value each patient’s insights.” When he sits down with an executive during the initial one- to two-hour meeting, he wants to hear everything about that person’s life, including health and vocational behaviors.
Stress, cognitive, and mental health assessments—if indicated—are essential to executive health visits. “We call it ‘coaching’ to make it clear that it’s a safe haven of confidentiality,” says Dr. Lang of Cleveland Clinic’s mental health evaluations, adding that, after patients have spent a few hours in the clinic, they are generally more comfortable discussing job-performance insecurity, infidelity, insomnia, or risky behaviors, for example.
When the day’s tests are complete and results are in, the physician generally meets with the patient again to go over the findings and, as needed, outline a plan that the patient can use as a reference and also share with his or her primary-care physician. “A lot of people choose this kind of exam, because they don’t go to doctors generally, so it’s one-stop shopping,” explains Dr. Lang. “For others, it’s like a life insurance policy. It gives them another view of their health to make sure they’re dotting all the i’s and crossing all the t’s, because they realize they need to have good health to take care of everything, whether it’s their families or their companies.”
Says Johns Hopkins’s Dr. Ashar, “No patient should leave here wishing they’d had a question answered.” However, if they do, they are welcome to contact their doctors and other practitioners via phone or email—a level of access that is extremely rare in the typical model of primary care.
In the current healthcare environment, such close relationships cannot be undervalued by either the patient or the hospital. Patients with significant financial resources are becoming increasingly vital to every medical institution’s ability to innovate and provide cutting-edge services, such as proton therapy for the treatment of cancer. Ansell, who describes the implementation of the ACA as a dynamic process, says that, in CHP, clinicians have the luxury of “having the focus on the individual patient drive decision making, rather than policy.”
The appeal among patients of being personally empowered to control decisions relating to their health care is growing. UCLA’s CHP treated 4,000 to 5,000 executives in 2013, a number that has grown by at least 9 percent in all but one of its 13 years of existence. Mayo Clinic’s Executive Health, which was founded in the late 1960s, now has a staff of 36 physicians, who saw some 6,000 patients through the first three quarters of 2013 alone. Though the majority of executive health patients live in the region of the facility they visit, many travel: Mayo accommodates 1,000 from overseas each year, while roughly 20 percent of the 1,200 who visit Johns Hopkins’s Executive Health Program annually come from parts of the U.S. other than Maryland or from other countries. And these numbers are likely to grow: Visits by international clients to all executive health programs, which dropped off after 9/11, have lately surged, becoming one of the promising new revenue streams that many hospitals hope to cultivate.
“Executive care came about because health care wasn’t patient-centered,” says Thomas Feeley, MD, the Helen Shafer Fly Distinguished Professor of Anesthesiology and head of the Institute for Cancer Care Innovation at MD Anderson Cancer Center. “In business, people understand who the customer is. In health care, people sometimes lose sight of who the customer is: It’s not the doctors. It’s the patient.”
The executive care programs, in turn, continue to support their host institutions and, as MGH’s Dr. Slavin points out, subsidize the margins of other disciplines. Mayo Clinic’s Kurt Carlson, MD, a consultant for executive and international medicine, notes that executive health patients tend to be generous where philanthropic gestures are concerned—an observation reinforced recently in the form of a $10 million gift from W. Hall Wendel, Jr., a grateful patient of that institution. That donation allowed the Mayo’s program to consolidate into a single center. But other benefactors choose to give open-ended, discretionary gifts. “Our clients have benefitted the hospital and even other areas of campus,” says UCLA’s Ansell, “not only directly through their payments for our services, but through voluntary philanthropic support of the many academic missions at UCLA.”
This close rapport between patient and hospital, though but one aspect of the nation’s rapidly evolving healthcare industry, is nevertheless crucial to its future viability. As healthcare connoisseurs, we must now, more than ever, embrace preventive care as a means of staying well, while at the same time forge stronger relationships with best-of-breed institutions to optimize our care should we or our loved ones become critically ill. Moreover, we must commit ourselves to supporting these institutions’ greater mission to push the boundaries of medical science and its application to patient needs beyond its present limits and into this new century, ensuring better health for all. The landscape will no doubt continue to shift in ways we have yet to imagine, but armed with both knowledge and personal connections to the best minds in the field, we may find ourselves on solid ground and in a place that is more oasis than desert, regardless of the changes ahead. ✦
Americans spent 2.6 trillion, or 17.9 percent of GDP, on health care in 2010.
Primary-care doctors in the United States make up just 12.3 percent of all physicians. In Australia, they comprise nearly 50 percent of all doctors.
The United States has the 3rd lowest mortality rate from stroke among its 17 peer countries.
Average life expectancy for U.S. women is nearly 81 years. For Japanese women, the average is closer to 86.
70 percent of U.S. adults reported being confident or very confident they would receive the most effective treatments if they fell seriously ill.
People with mental illness consume 44 percent of all cigarettes in the United States.
The percentage of U.S. adults at high risk for cardiac events exceeds the European percentage by more than 159 percent for women and 34 percent for men.
26 percent of Americans reported having a mental health disorder over a 12-month period.
Median per-capita health spending in the United States in 2009 was $7,960—twice as much as the $3,223 per capita spent by peer countries.
In 2010, 50 million Americans were uninsured.
84.1 percent of U.S. survey respondents ages 18–65 report engaging in moderate or vigorous activity in a typical week.
Life expectancy of a 25-year-old U.S. man without a high school diploma is 9.3 years shorter than for one with a bachelor’s degree.
*Statistics have been taken from a 2013 report conducted by the Institute of Medicine and National Research Council comparing health outcomes in the United States to those of 16 other high-income countries, which include Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, the Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, and the United Kingdom.