by Tony Chen

I recently picked up Inc's list of the 500 fastest growing private companies in America. #1 must be some technology company, or maybe a new company in energy, right? Much to my surprise, it is Senior Whole Health, a company that specializes in healthcare and other services for (wait for it...) the elderly poor.

Huh? How does a company grow 31,000%+ over 3 years focused on the infamously dubbed "dual-eligibles" (Medicare and Medicaid). As with any company with such success, they offer a compelling value proposition.

Through working with their state government, they created a new type of entity, called Senior Care Organizations (SCOs) that keeps folks out of nursing homes or in the least restrictive setting possible. SCOs are essentially the conglomeration of all the services required to meet that objective - nurses on phone call, physician tracking, and EMR systems. The key resource, though, is the community resource coordinator (think of a patient advocate/home nurse/social worker hybrid), that visits every new enrollee and arranges for whatever is necessary - housing, electric scooters, Meals on Wheels, adult day care, etc.

The money quote from their chairman Outland:

"We don't have a cost avoidance strategy. It's about care management improvement, which translates into quality-of-life improvement, which trickles down into cost savings."

They now have almost 6,000 members and have a revenue of $147MM in 2007. But don't get any ideas just yet to start something like this in your neck of the woods. Remember that this start-up actually "started" in the state legislature first.

Nonetheless, this is social innovation at its best. Adding tremendous value to particular niche of society (they originally wanted to do this non-profit) while landing on a sustainable and scalable business model.

Guest Post by Kristin Baird

Reputations are based on word of mouth. No amount of advertising will build the type of trust that you want from patients, their families and ultimately the community that you serve. You have to earn it. And you will only earn it through consistently positive experiences. No matter how much quality data we publish, people will gauge quality through their personal experiences. Consumers expect clinical competence but make decisions based on how the encounter made them feel. That means that even one disengaged employee can leave a patient and their family feeling nervous, insulted and on edge about the care.

Take my uncle Don’s experience for example. Last week he was hospitalized with a severe infection in one of his vertebrae requiring six weeks of inpatient care for round-the-clock intravenous antibiotics. Don is a fairly stoic man who is no stranger to physical work. But by the time he was admitted he was in such intense pain he could not walk and had to be wheeled to his room. A nurse admitted him to his room and dropped off some personal supplies. She said, “Here’s a urinal and wash basin. I couldn’t find one of those things that you puke in, so if you feel sick I guess you’ll have to use this,” she said holding up his wash basin. She turned on her heel and headed for the door.

Don spoke up and told her that he needed to go to the bathroom. She turned back and said, “What do you want me to do about it?” She pointed at the supplies she had delivered and said, “There’s the urinal and there’s the bathroom. You walked in here on your own, I’m sure you can manage,” and out she went. My aunt Joan was left to help him. She later called me in tears. As the “family nurse” it’s not uncommon for me to get calls from my parents, siblings, aunts, uncles and cousins requesting my input on their choices of hospitals, physicians and treatment regimens.

Joan had to drive 90 minutes each way to the hospital to which Don was admitted and wanted to have him transferred to a hospital closer to her home. She gave me the names of two hospitals within ten miles of her home. I talked to her about what was most important to her and then introduced her to the hospitalcompare.hhs.gov website. I talked her through how to compare the three hospitals based on the published data. We noted that the two hospitals closest to their home had the lowest scores for clinical quality and patient satisfaction. The one where he was currently an inpatient had the highest all around scores.

Ultimately, she decided to move him to the one closest to home insisting that the data just couldn’t be right. Her good friends had been patients locally and told her that they had gotten excellent care at the local hospital. And besides, she had witnessed first-hand how the staff treated Don in the high-scoring hospital. This was all she needed to know about quality. Her experience was her reality and there could be no arguing about that.

It comes down to this; seeing is believing, but feeling is the truth. Each patient’s experiences become his reality. Health care leaders who want to protect their organization’s reputation and instill trust among their patients, must continually strive to create consistently positive patient experiences. They need to set the same high expectations for service as they do for compliance with clinical protocols. A competent leader wouldn’t dream of letting clinical practices slide because someone is having a bad day. And yet, he may tolerate the poor or marginal service behaviors among his staff, underestimating the power that they have to destroy the organization’s reputation in as little as a thirty second encounter.

Fostering a culture of service excellence is achievable. But it can only happen when leaders set clear priorities, hire, develop and recognize the right people, support them with effective and efficient processes and assist each individual in developing a strong sense of purpose. Then and only then will they be able to raise the bar on service excellence.

Kristin Baird, RN, BSN, MHA is the author of Raising the Bar on Service Excellence (2008) and is president of Baird Consulting, Inc., a firm which specializes in results-oriented customer service solutions for health care organizations. She can be reached at kris@baird-consulting.com

by Christopher Cornue

So much of the research and literature out there speaks to the uninsured, which is an issue that needs immediate attention; however, there is an increasing group of individuals for which a focus is necessary. According to the recently published report by The Commonwealth Fund, How Many are Underinsured? Trends Among US Adults, 2003 and 2007, there are an estimated 25 million underinsured individuals in the US, which is a staggering 60 percent increase from 2003. The majority of this increase is in the middle class, while low-income households remain at significant risk as well. The report details how folks are identified as underinsured (which is very interesting) and specific groups that are hit the hardest. The biggest concern with this is that often care is not sought, which obviously impacts the health of the individual and will eventually add additional costs to the healthcare system down the line. As with issues we?ve raised in the past, one of the biggest issues we have is ensuring that preventative care occurs on an ongoing basis. This underinsured issue will only complicate our health care system challenge further.

by Tony Chen

If you've been following Hospital Impact, you'll be very familiar with the voice of Nick Jacobs. If not, let me give you a quick intro: He's a middle school band teacher turned hospital CEO in a mining town that had no business surviving the loss of their mining industry. Some would even say that Jacobs helped save the town through the hospital he led and transformed, Windber Medical Center. Instead of dying a slow death, the small community hospital is now internationally known for innovation, for proteomic research, and for its patient-centric healing environment. Not a likely place for the largest breast tissue bank in the country or the daily smell of freshly baked bread, wouldn't you say?

Nick has been blogging here at Hospital Impact for almost 3 years (which is like 15 years in the real world), sharing insights and tidbits on everything from housekeeping to transparency to leadership. His passion for healthcare is contagious and he has been taking the hell out of healthcare for decades.

As such, Nick has recently released a book (get it on amazon.com) that talks exactly to that point. Whether you're a patient, a family member of a patient, a physician, or a hospital administrator, read this book for an insider's look into hospital care, and how you can get the best care possible at your next visit. And as hospital leaders, this book will remind us again to see our patients as people - something that we as administrators can forget sometimes when we are surrounded by ppt, xls, and doc all day long.

Check it out, and let me know what you think!

by Nick Jacobs

As we struggle on daily through the newly established higher fuel prices, several surprises have sprung up about which many of us have been oblivious. Corn, for example, had become the American epitome of green. If we could grow enough corn to make ethanol, life would be fine. Then, we were accused of causing food shortages world-wide because we used this precious food commodity to inefficiently produce a little extra enhanced gasoline product which, at least my oil distributor friends tell me cause your car to get less mileage. Why not sugar cane or grass or left over cooking oil from the fast food restaurants?

It became clear almost immediately that everything from the cost of picking up your garbage to the price of groceries has been seriously impacted by this growing cost of fuel. Hospitals and Health Networks magazine ran an article this month about the negative impact of these gas prices on, of all things, ambulance service. Who would have ever thought?

The article explained that the higher cost of fuel was making some ambulance organizations rethink their fleet sizes, their ability to field as many crews, and, consequently, their ability to respond to your needs. According to H&HN Medicare has always under funded ambulance companies by as much as 6%, and with as much as a 300% operating cost increase, the math just doesn’t work.

Could it possibly be one more problem created by our dependence on foreign oil? Could it be one more reason why we should begin to imitate our European partners? Could it be one more example of just how serious this situation is?

Last week India introduced an automobile that runs on air. Unfortunately, it seems that, for the last twelve years Washington D.C. has run on the same thing. Of course, to quote a friend, by the time we add the United States safety mandates such as airbags, crumple zones, break-away engine mounts, impact-absorbing bumpers, 3-point seat belts, child anchor systems et al, you have a $25,000 balloon that can’t do 35mph and have no chance of fitting 2 car seats and 25 Wal-Mart bags at the same time. Go figure. Maybe the funeral homes will start back their ambulance services?

Guest Post by Heather Johnson

Over the last several years, much has been done to attempt to “fix” health care, hospitals, and public health. With somewhat noble intentions, new laws like HIPAA have been passed, as have innovations in the way hospitals do business, treat patients, and promote themselves in general. One thing is missing, however: the public still lacks the necessary faith in hospitals as well as the health care system in general. The fact of the matter is many people still wait until it is almost too late to receive much-needed care and treatment.

You Can Change the Look, But Not the Feel

Many hospitals have gone to giving some or all of their rooms the hotel or resort look in order to eliminate the sterile feeling hospitals give some patients. The thought process is correct here; however, you cannot simply make things look different and expect a shift in the quality of care to occur. If patients and relatives are not treated like guests, it does not matter how well-decorated the room is. Bedside manner and a smile go a long way in helping patients to feel at home.

Falling Through the Cracks: The Middle-Class Gap

Currently in the United States, there are two groups of people that seem to get their health care needs met: the wealthy and the extremely poor. People with money can afford the treatments and care needed to sustain their quality of life. Conversely, the poor can utilize Medicaid, which covers most, if not all, of the costs when it comes to receiving treatment at a hospital, especially when it comes to maternity care. Of course, the poor may not be getting the care they need until the last minute, but they are covered nonetheless—without the fear of being unable to pay.

One of the biggest problems with the current state of health care is that middle-class people fall into the gap between the haves and the have-nots. Many lower middle-class people make just enough to not qualify for Medicaid, but cannot afford health insurance. With the rising costs of hospital care and health care in general, these people are simply unable to afford to get the care they need. Some are reluctant to visit the hospital, even when they may really need to, out of fear that unpaid medical bills will ruin their credit.

Shifting Mentality: What is Needed to Change Public Perception

Getting back to the basic principle of treat everyone how you would like to be treated is the main focus here. A great bedside manner goes a long way, as does a smile. Taking time (even when it feels like there is none) to talk with patients and get to know them makes people feel better. People need to know that hospitals and health care professionals are not “out to get them.” A lot could be done for the hospital industry if people demonstrated a little compassion for those who are unable to pay right away as well. Hospitals are a business, most definitely, but at what cost?

This post was contributed by Heather Johnson, who writes on the subject of top nursing schools. She invites your feedback at heatherjohnson2323 at gmail dot com.

by Nick Jacobs

Penn and Teller, magician-comedians, have a cable TV show that basically explores all aspects of life in America with the intention of exposing those areas that are not valid. I'm not sure why the noble bull has suffered this indignity of their show's title, but, when it comes to making fun of the nontraditional, these magic men hold nothing back. They look at topics like integrative medicine, snake charming, and sensitivity training through their sarcastic, unprofessionally trained eyes and do all that they can to rebuke the topics being explored.

Recently, the Sunday New York Times ran a front page article written by John Leland entitled “Fast Forwarding to 85, to Better Aid Elderly.” The primary theme of this piece revolved around a type of sensitivity training for employees and family members that would enable them to grasp the disparaging aftermath that can result from those oft times not so golden years. In this article, Mr. Leland helps us discover the merits of a more humane type of patient-centered care.

Examples used to sensitize the participants included: special glasses that blurred their vision, cotton balls in their ears to lessen the acuity of hearing, and in the nose to cut down on their ability to smell; kernels of dried corn in shoes to accentuate the loss of fatty tissue on the bottoms of your feet, and latex gloves with adhesive bands around the knuckles to simulate arthritis.

They also ask you to make post it notes with your favorite possessions, lists of your favorite friends and relatives, your most cherished freedoms and or past times. Then they compel the participants to give up each of these until there are only two left. This exercise is intended to be representative of the lives of those who end up in some forms of long term care.

Ten or so years ago we embraced a similar program intended to sensitize hospital employees to the trials and tribulations of just being a hospital patient. The full thrust of this program, the Planetree method, was to empower patients, to de-mystify their stay, and to allow them to keep their dignity. This training included blind folding, moving people in wheelchairs, and having one employee feed another. Conversely, it also added loved ones to the mix, gave patients access to their medical records, and even provided them with pajama bottoms to protect their bottoms and their dignity.

Although Penn and Teller may find humor in this type of training, those individuals who have experienced a center that utilizes these techniques, be it Planetree, Eden, or simply a place where, like those philosophies embraced by the Samueli Institute, Optimal Healing Environments exist, patient satisfaction typically can reach into the 98th or 99th percentile. HCHAPS or Hospital Consumer Assessment of Healthcare Providers and Systems scores soar into the top 10% nationwide.

So, the title of this piece could easily have been, “It Ain’t Rocket Science,” because it surely is not. It is about drawing attention to other’s feelings, adapting to the needs of those who are at risk or to those who are under an enormous amount of stress. It also, however, is about providing that same level of attention to the employees responsible for the care and nurturing of those patients, clients, and loved ones.

All too often the hospitalization and nursing experiences that we endure often remind me of the late Sydney Pollock’s movie, “They Shoot Horses, Don’t They” in which Gloria, a young woman of the Depression who has aged beyond her years and feels her life is hopeless, enters a dance marathon. The grueling dancing takes its toll on Gloria's already weakened spirit, and she tells Robert that she'd be better off dead.

There are alternatives to these feelings of hopelessness. If we stop treating our employees and our patients like commodities, and sensitize them to the realities of our patients, we will reap the benefits all around.

by Nick Jacobs

When the word quality was discussed back in the 80's, you often heard of the Baldridge Award or TQM, total quality management, as the programs that would take your organization to new heights. Today, more often than not, we hear about the Toyota Model of management or a more dated Six Sigma, 99.999999% approach to perfection. Recently, though, the government has taken over the quality quest in health care to push this industry to achieve levels of perfection.

U.S. medicine is about to launch into a new world order that will functionally save the government money, but will it produce quality? Of course, when it comes to life and death issues, there is no question that we must strive toward perfection, but when it just comes to human beings attempting to function in this very competitive environment, the game change causes casualties for both the providers and the patients.

The Government is taking a three-pronged approach to improve quality in health care:

1. They are pushing quality through public reporting. 2. Enforcing quality through the False Claims Act. 3. Incentivizing quality through payment reform.

Senator Chuck Grassley is quoted as saying, "Today, Medicare rewards poor quality care. That is just plain wrong, and we need to address this problem." HMO's are currently embracing "pay for performance" plans for physicians and hospitals. Medicare is introducing value based purchase plans and is proposing the linking of quality outcomes to physician payments.

As I have written before, hospitals will no longer be paid for hospital acquired conditions. That seems like a rather simple fix, but to appropriately determine if the condition was not acquired at the hospital, extensive testing must be added pre-admission at considerable costs to the hospitals. These additional unrecompensed costs be balanced by having fewer employees per patient, less updated equipment, and less flexibility to use more expensive drugs, but it will determine if your infection was present upon admission.

James G. Sheehan, Medicaid Inspector General of New York said, "We are reviewing assorted sources of quality information on your facility to see what it says and if it is consistent. You should be doing the same."

The spoken goal is to work toward perfection, but the underlying goals are also directed toward the financial implications. The public reporting of quality of care is intended to: correct inappropriate behavior; identify over payments, or deny payments altogether.

The False Claims Act, on the other hand has more draconian goals. When asked how he viewed the False Claims Act, Kirk Ogrosky, Deputy Chief for Health Care Fraud said, "You will see more and more physicians going to jail." Just what we need when there aren't enough docs to go around now.

Will these changes improve health care delivery? For the patients who can find the few docs and hospitals that will be left, there may be some improvement, but my personal opinion is that it will break the back of an already broken system and force more small and mid-sized hospitals out of business.

I recently had a conversation with a young medical computer specialist who took care of physician practices. He said, "Doctors and hospitals haven't figured it out yet, but they are simply becoming data entry centers for 'Big Brother' as the facts and figures are accumulated to be used against them in any manner that the payers may decide."

Maybe this is all too complicated to get our arms around, but if there are 78 M Baby Boomers and the Medicare Trust Fund is heading toward bankruptcy, then we probably will see every rule in the book being applied to keep from paying hospitals and doctors. There will simply not be enough money to go around.

Is that quality? Will these initiatives improve health care?

Prevention, wellness, optimal healing environments, and systems approaches to health and wellness will improve healthcare. Improvement will not come from the new rules that are unfolding. They may save some money, but how many lives?

by Nick Jacobs

Transparency in healthcare will facilitate the improvement of performance and quality by providing hospitals and physicians with the additional information necessary for benchmarking their work. It will obviously assist patients as they attempt to make informed decisions regarding their potential care. Finally, transparency will improve quality and efficiency by encouraging private insurers and public programs through providing necessary information to them to make necessary decisions. Transparency is not the end-all, but it is a solid start.

Having dealt with insurance companies, car dealers, computer sales specialists, architects, construction companies, stock brokers, and any number of other professions, it is obvious that any steps toward transparency would significantly move us in the right direction, toward truth, justice and the American way, but none of these topics raise as much passion as conversations about transparency in healthcare.

A little over a year ago, I was informed that a retirement policy endorsed by a former employer had gone bad, and, co-incidentally, it had cost me five years of my personal savings. Could a lack of transparency that may have resulted in personal gain for those involved in selling the product have contributed? One can only guess.

When we realize that we have lost hard earned money, the result is anger, disillusionment, and frustration. When, however, we realize that a loved one has lost their ability to walk because of a lack of information needed to make an appropriate clinical decision, the passion becomes significantly more extreme. We talk a lot about transparency in healthcare, but, not unlike most professions, the jargon, complexity, and intricacies of the profession's jargon keep all but the most learned individuals from sorting through the risks and rewards of each clinical decision.

Do you want coated or uncoated stents? Should you try controlling this situation with medication, open heart surgery or angioplasty? Will I do better with 20 mg. of cholesterol medicine or 40 mg. and what is the potential side affect of this new drug? These questions are incredibly complex, individual, sometimes life and death oriented questions. Simple transparency is not necessarily the answer here.

Let’s be candid and face the stark realities of transparency. Patients are, by and large, the least prepared to command greater quality. Usually we are facing these hard-hitting decisions when we are experiencing some type of health crisis. Shopping for the best of anything at that time is improbable. To further complicate things, the power of an individual as weighed against that of an insurance company, all levels of government, and the myriad of professional societies is infinitesimal when it comes to influencing transparency related issues.

Sara R. Collins, PhD. and Karen Davis, PhD. in their article “Transparency in Health Care: The Time Has Come” written for the Commonwealth Fund, describe the fact that higher patient cost-sharing and high deductible health plans are the wrong prescription; that price information is of little or no value, and that the current state of information is inadequate. They do suggest that the following steps should be considered:

Medicare should take a leadership role in requiring more transparency.

A National Quality Coordination Board should be established.

Continued investment in health information technology must be embraced.

Fundamental changes should occur within current payment methods.

And Health Savings Account legislation to reduce potentially harmful effect on vulnerable populations should be enacted.

They conclude that price transparency is a good beginning step but only a beginning.

With my two decades of healthcare experience securely tucked away, it is important to recognize that we all have the right to question, the right to look for outcome results, and the permission to get the information needed to help us make informed decisions about our personal futures.

by Tony Chen

Can we stop talking about retail clinics as an "emerging" trend? These clinics are here to stay. Plus, there's already 1,000 of them (as we predicted almost 2 years ago), and probably thousands more on the way.

Yes, there have been hiccups. Physician-staffed clinics have not done well for obvious cost/business model reasons. A few NP-staffed clinics haven't done well because of over expansion -- most notably, CheckUps (which had clinics in WalMart locations) closed 23 clinics. They had just grown too fast. Too many acquisitions too quickly = no cash flow. Other NP-staffed clinics have done very well, and why wouldn't they? A couple patients an hour, and boom, it's a profitable business.

Now that retail clinics are part of the healthcare reality, the real question is this: how far upstream will they try to expand their scope?

We have at least 2 indications that they're just getting started:

- Walgreens has recently drastically shifted strategies. They aren't focused on opening more stores anymore (like they have been for the last 10 years). Nope, they're focused on leveraging their growing portfolio of health care service access points. Besides adding new services to their retail clinics, they've also recently acquired hundreds of worksite clinics. They've created a "health and wellness" division and are aiming to have 10,000 healthcare access points in 4 years. Get ready, hospitals and physician offices, Walgreens is creating a healthcare system of care right where people work and live.

- A recent article from AAFP also concludes that future retail clinics will also provide chronic disease management, injections, weight loss counseling, and more. The money quote from Mary Kate Scott, now the key guru on the topic:

This has happened in just about every industry. By providing just a small set of services and doing it again and again, you actually can bring down the cost and increase the quality. Take Jiffy Lube and Midas. Jiffy Lube said, "All we're going to do is change oil," and Midas said, "All we're going to do is brakes." And someone came along and said, "We won't charge you what a mechanic charges, because we're going to use a technician, not a mechanic." And slowly they've expanded their services.

And I gotta tell ya. I love Jiffy Lube - their "EMR" on my car is better than the one I have at my dealer. Just wait until Walgreens puts in place those auto-alerts that Jiffy Lube mechanics use so well ("did you know you're due for your 30,000 mile...").

UPDATE: WalMart is also getting into the telemedicine biz.