A common Question: Where Are Inpatient Volumes Going?

One of the most common questions being asked by a myriad of audiences- leaders in the C-Suite, physicians, pharmaceutical companies, insurers, supply chain companies, and investors - where are inpatient hospital volumes going? It is clear to me, for a variety of reasons, that these volumes at best are going to remain flat, and most probably are going to decline 2% to 4% annually for the next decade. The question that must be answered if the "Why" - what are the reasons for this picture of future volumes unfolding.

The first, and probably the most significant reason, is the recent economic crisis, which, although it has softened, is still influencing the volumes negatively, and will undoubtedly continue to do so in the future. The resulting high unemployment rate drives a higher number of uninsured, all of whom are reluctant to seek necessary care, let alone elective procedures. The unemployment rate is not expected to decline significantly in the near and mid-term future.

The second reason, which is the best and most positive reason, is the rapid advancements of technologies which have premitted many of the once inpatient procedures to be done in the outpatients areas. These procedures, often demanding less reimbusements, are safer and less painful for the patient. The resultant outcomes, thankfully,  are the drivers of the two crtieria for successful healthcare services  in ther future - those which abd demonstrate high quality and low cost.

A third reason is the acceptance now by many that what I have been saying for years is true.....there is a great deal of overutilization of treatments and procedures that are unnecessary, often leading to even a worsening of the patients' problems. This acceptance and recognition by CMS, insurers, quality and utilization healthcare leaders, physicians, and even the patients themselves, are causing this overutilization to be addressed, being replaced by evidenced-based medical protocols. Hopefully in the future we will be doing procedures only because they are required, not because we can because the equipment is available. This oversue is presently most evident in cardilogy (cardiac caths and stents), gastroenterology (endocopies), and radiology (MRI and Cat Scans).

And finally, many people, faced with the negative outcomes of the economic crisis, have used self medication and alternative and complimentary medicine treatment plans to address their complaints. Becasue many of these pathways have been successful, these people will not quickly return  to the traditional medicines of the past.

In adiition, I have mentioned in previous blogs that probably 1/4 of our present hopsitals will close in the next decade. We also are recently hearing that an increasing number of employers are comtemplating taking the penalty instead of providing health insurance for their employees. Both tof these events will only make the inpatient volumes decline more severe. Yes, we are an overbedded hospital industry in the United States in this present moment. If the reasons for volume declines articulated above are only half true, what should the hospital of the future look like?  Today, the number of beds available, versus the number of occupied beds show a gab of over 20%. If beds are not permanetly closed and /or converted to other uses, this gap will only increase. Hopefully, the leaders of healthcare will do what is necessary to "right their ship" and make sure the volumes of the future are only the necessary ones....critically important for we know they will be judged on value not volume going forward!

Being a Change Agent - the Critical Competency

There is hardly a day that goes by when the newspapers and TV news broadcasts are not sharing an important set of new inofrmation concerning the healthcare delivery process in the US. Just last week, two important articles were headlined......
         "Study: ERs shrink as demand rises"
         "New Nerve Stinulation Technological Makes a Paraplegic Walk"
Both of these articles reinforce my belief that the hospital of the future will look very different than that of the past and two major drivers of healthcare will continue to be the access point for the patients to recieve their initial care, and the technology that will be available to diagnosis and treat them.
Inorder to be successful in the future, I have been stating that healthcare systems will need to be capabale of providing  high quality, low cost products and services. The ability to achieve these goals is to assure that the patient receives their primary evaluation as quickly as possible, and that the addition diagnosis and treatment plans required are well coordinated. Certianly the trauma side of our Emergency Departments are not the place for the average non-acute patient to be seen. However, because of the lack of primary care entry points in the US due to the paucity of primary care physicians, and the reluctance of many physicians to embrace physisican extenders, most Emergency Departments have created non-acute tracks that function much like a primary care doctor's office, and make them available often 24 hours a day, but if not, at least 10am to 10pm. Recognizing that these non-urgent care tracks provide a stop-gap measure for many patients until we solve the primary care capacity issue, what will be the change needed to address the fact that the first article indicated that 1 in 3 ERs have closed over the last two decades. And even more serious consequences come from the reasons for the closures........
       >Have low profit margins
       >Serve patients below the proverty level
       >Serve those with lower forms of insurance, including Medicaid
       >Those in for-profit hospitals
       >The ones located in more competitive markets
All of these reasons cause problems for a large number of patients in the US who have, at this time, no other access point.
With regard to the new nerve stimulation technology story, this is supporting our prediction that neurosurgey will be a growing and changing service line which will provide more and new tretaments in both the inpatient and outpatients settings. These treatment plans will require much more space for intense reabilitation which, in the past, has not alwyas been profitable and therefore have not been incorparated into the offerings of many local and regional medical centers. And long reabilitations times for any patient are not best delivered miles from where the patient's family and support persons live on a daily basis. And if this technology can be made afforable and expandable to many other quads and paraplegics, present technolgies such as rotating beds, electrtic wheel chairs, and services such as "help dogs" and visitng home nurses may have to change what they are doing to serve the patients of the future, not the past!
What does all this mean for people working directly or indirectly, in tthe healthcare industry. Change will continue to occur at a rapid pace, and those that can embrace these changes with enthusiam and with passion will be both the formal and informal leaders of the future. Yes, being a change agent may be the most critical competency for healthcare providers as the future unfolds! these are interesting times, worth watching closely.

Understanding the Brain as Well as the Heart!

As we envision the hospital of the future and the service lines that will be offered in the acute setting, it is important to recall a prediction in a prior blog that "in five to eight years we will know as much about the brain as we know today about the heart". The outstanding preventive care, as well as, treatment plans that we can now offer cardiac patients is astounding and, as a result, cardic disease will soon fall behind cancer as the number one killer in the US, quickly followed by trauma., which is catching up fast (see prior blogs on this topic). It is important to note that all this advanced care for the heart, including the training of paramedics, the development of mobile ICU's , the staffing of cardiac care units, and the development of coronary artery stents occurred in the last 25 to 30 years. And now heart bumps to supplement failing heart muscle are becoming common place. All of this proves, that with focus, much progress can be made in a relatively short period of time.
Using that as a predictor of the future, I am comfortable that we are making rapid discoveries surrounding brain diseases and therefore, we are approaching the time we will know how to treat and even prevent significant brain abnormalities such as alzheimer's,  parkinson's, and other chronic dementia abnormalities. We have all ready seen significant advances in stroke prevention, as well as stroke reabilitation. The preventive measures are now being spread to small community hospitals through neurological telemedicine programs, where neuro specialists, both doctors and nurses, are available 24 hours a day to observe patients in any Emergency Department with the video equipment, guiding the local staff through the appropriate treatment plans. Numerous bairn tumors, including metastatic ones, are sucessfully remorved with stereotactic and cyber-knife techniques.
In addition to all of this great progress, we are now reading about potential treatments for parkinson disease patients using techniques to deliever drugs directly to the brain, which has been difficult in the past due to the
blood-brain barrier which inhibits normal drugs from developing high concentrations in the fluid surrounding the brain and the spinal cord. These treatments will use drug  pumps and catherters, which will require insertion in ambulatory surgery centers or in the inpatient setting for a 1 or 2 day stay. We all ready have successful treatments for some parkinson patients who have benefited from implanted electrodes that provides electric stimulations to parts of the brain that control the disease process.
How will all of this effect the healthcare industry? Some of the beds now empty in the inpatient settings because of ability to care for many patients totally in the outpatient setting will start to be filled with patients getting new therapies for brain disorders. "Brain Centers", encompassing a wide variety of treatments, some curative,  for a large number of now untreatable brain abnormalities will spring up across the country, much like the national cancer center movement we are now seeing. Locked units for dimential patients will have to change and perhaps will no longer be needed. Wouldn't that be wonderful.
We learned alot about the heart in a short period of time. We had to because of the number of people who were affected by cardiac disease. As we are successfully treating many heart patients helping them to leave more healthy lives and as the population continues to age, abnormalities of the brain are moving to the forefront. As it was the "heart's time" 25 years ago, it is now the "brain's time". Sit back and watch as we learn as much about the brain as we know about the heart!

Prior Predicition Appear as Today's Realities

Two articles pasted by my computer this week which caused me to recollect blogs that I have published over the last several year, making predictions that now appear are becoming today's realities in  health care delivery.
The first article stated that "As technologies empower patients to control their health care journeys, hospitals may downsize to the point where they will povide only advanced trauma and critical care. Declining inpatient and increasing outpatient business are signals of the impending change". In previous blogs I gave numerous reasons why hospitals and healthcare systems should be moving to increase their services lines in the non-acute programs, including home care, hospice, palliative care, and even retail services, along with the more traditional outpatient offerings. Some of the reasons for these changes included:
       >The increasing development and use of non-invasive technologies
       >The increasing safety of anesthesia and surgical techniques exploding the use of ambulatory surgical centers doing procedures now not even requiring a one night stay
       >The expanding use of outpatient cancer treatments because of the decreasing toxiciiy of the drug therapies
       >The ability of many invasive cardiac procedures to be delivered in an outpatient setting
       >Trauma becoming the leading cause of death in people 57 years and younger and moving higher. As I indicated before, trauma was the leading cause of death in children 7 years and younger when I trained, the significant rise casued by our abilities now to identify and treat diseases which killed many people in the past at a much younger age.

All these reasons are still valid, and cause one to suggest that all leaders of healthcare today should ask two important questions:
       1. Are we creating the hospital of the future rather than supporting the hospital of the past?
       2. Are we allocating a sufficent portion of our capital to developing and implementing non-acute service lines?

I strongly believe that both of these questions must be answered in the affirmative if a sustainable healthcare delivery system is to be achieved which can providethe high quality, low cost care which is imperative for future sucess.

The second article stated that "cat scans are used 30% more in Pediatric Emergency Rooms where they are readily available with no proof that the treatment outcomes are better". As you have read in numerous of my previous blogs, I have reitierated that the high cost of healthcare in the United States is due to overuse of equipment and studes, and not misuse or underuse. I also have written that many studies get done because we can do them, not because we should do them. They get done, as is the case in these pediatrics ERs, because the equipment is available. Oh we know that some parents demand that the studies be done, and physicians say that they need to do them to minimize their exposure. But this probably accounts for only 5% of the overuse. What about the other 95%? Could it be due to the need for us to maximize our revenues?  Over 30 years ago in the Emergency Dept. at the Geisinger Medical Center we proved that skull xrays did not alter the treatment plan or medical outcome in children who had mild head injuries with no physical skull deformity and no history of being unconscious. So we stopped doing them! Changing the present trends will not be easy, but the answer is clear. Treatment plans must be driven by evidenced -based protocols which drive high quality and low costs which are aligned with the best reimbursement for both hospitals and physicians!

It is clear, by studying the past and the present, some future predicitions can be made, that can become the reality quickly. Will you be ready?
      

The Importance of Awards

Last week I had the honor of receiving two awards. I was made an Honorary Fellow of the American College of Physician Executives and received the Distinguished Service Award from the American Hospital Association. Receiving such awards are important for two reasons. First.....it give the awardee the opportunity to thanks all those people who surrounded him or her to make this award possible. I did just that. Ifirst thanked my wife, children and friends who have supported my career for many years. I then recognized and thanked the excellent teams I have been able to work with at Geisinger, Johns Hopkins, Henry Ford, and CHRISTUS Health. Second...it gives the awardee the opportunity to make brief remarks from his or her life's learnings that hopefully will motivate the audience as they depart. Since these award ceremonies were only fours days apart, I shared similar thoughtsd at each. They included some of my teachings in prior blogs and wnet something like this......
       We all know that we are facing some of the most challenging and complex times in healthcare. Inorder to be successful leaders of tomorrow, which will look different than leadership of today, we will need to enhance our leadership competencies, committment, and passion. With regard to the competencies, they are well defined and I have articulated the ones I believe are most critical for the future in published articles and prior blogs. These can be learned or enhanced by attending conferences and workshops that occured at both meetings where the awards were  given. In addition, compentences can be sharpened by reading, and sharing best practices by colleagues. Committment is strengthened by each team member individually and the team collectively reaffirming that heathcare leadership is where they want to focus their energy at this moment in time. But I have concerns that in challeging times, it may be very hard to maintain the high level of passion for your work that is critical if other pewople are willining to follow you. Therefore, I want to share three of my life's learning regarding how to grow one's passion which I define as "the place where the love of your work lives." They are:
        1. Never forget that healthcare is a sacred ministry. Not sacred in a religious sense, but sacred becaus each day people come through our doors and turn their most precious gift over to us...the gift of their life or the life of their loved one or child. This is an awesome responsiblity and demands that excellence is a necessity and not a luxury for all those we serve.
       2. Confirm that you are called each day to your work in this sacred ministy, wherever you serve. If you come to work each day doin a job, at best you will leave having done satisfactory work. If you labor as a professional each day, you will do meaningful work. But if you are truly called to your work, you will be a transformational leader, taking waht is today and transforming it into waht it must be tomorrow.
       3. Pause and ask the question, "Could this be one of the reasons why I was put on this earth?" I have asked that question several times on my life's journey both as a clinical leader and physician executive. When you answer that question in the affirmative, you know for sure that you have been called, and you will always answer "YES" to the most important question, "Is it worth it to be a leader in healthcare today?"

I closed my remarks by stating that I gegan my carrer in healthcare at age 15 as an OR Technician at the Centre Community Hospital in Bellefonte, Pa. I worked almost full time to pujt myself through college and medical school. When  I began, I kew it was never going to be easy. It never has been! I knew it was going to be possible. It always has been!  And finally, I knew that each day I worked in healthcare would bring great meaning to those my team and I served. It truly has done just that!

The Two Leadership Questions

At the conclusion of last week's blog, I indicated I would articulate the two important questions you must ask yourself if you want to be a successful leader in healthcare today. This applies whether you are leading a work group, a task force, or you areon the C-Suite Team. Everyone who tries to lead, both formally and informally, should pause periodically and not only pose to themselves the following two questions, but make sure that they answer the questions as objectively as possible. The questions are.....
     1. Why would anyone want to follow me?
     2. What do they see when they see me coming?
It is abundantely clear that in order to lead, some one or some group must be willing to follow you. They follow because they trust you, they accept your rationale for creating the direction that you are leading them in, and they believe that what you are doing is in sync with the Mission, Vision, and Values of the organization. It is vitally important if they are going to continue to follow you, especially during very challenging and complex times, that these qualities are what they see when they see you coming...coming down the hall, greeting them in the morning, or entering the meeting room. Great leaders are credible leaders, and this credibilty is gained by always "walking the talk", rather then just "talking the talk". And what is most important to remember is that this trust and credibility can be lost quickly, and once lost, is very hard to regain. Great leadership is required to creat a great company. But as I have studied how to achieve  excellence, I have determined, as have many others, that reaching excellence is a lot easier than sustaining excellence. A clear example is Southwest Airlines, unquestionalbly one of the best airlines for many years, as evidence by many comparable industry metrics. However, in the last year, Southwest  has fallen to third place overall in national airline rankings, and their recent and past maintenance problems are raising concerns for many that perhaps the quality that has been taken for granted is now in qustion. To remain at the top requires a continuous monitoring of the brand and changing whatever needs to be changed that is weakening the brand. Change in healthcare is critical, it is constant, and it is exciting. Accepting and adapting to change is critical. Why? Because our happiness and personal satisfaction in our personal and professional lifes depend on it! Being a leader is challenging, never easy, always possible, and very rewarding. Asking and answering the two questions presented in this blog will go along way to quarantee that your style of leadership will be successful.

Adapting to the New Healthcare Market - Part II

As I indicated in last week's blog, I would articulae in this blog the six ways we can reignite the enthusiam and create not only a sustaining, but also thriving healthcare industry and environment. These are: 1. Agree that sustainable care must be high quality/low cost, affordable, and accessible to all. These paramenters are the driving forces embedded in the new healthcare reform act, and are important goals. These are goals that we, as all the various players in the healthcare market - providers, insurers, and vendors - should have had always as are ultimate goals for the roles we are playing in the delivery system. Clearly, we can only accomplish these goals by not only reducing our labor and supply costs, but by enhancing our revenue cycle processes and retructuring our clinical processes using medical portocols driven by the enormous amount of evidenced-based research that has been done, documented, and shared. 2. Physician voices must be heard. Assuming that physicians will express their opinions, along with the rationale for those opinions, in a professional manner, there voices must be listened to carefully, and incorporated as appropriate into the operational and strategic plans of the healthcare delivery process. This can be done through involving or providing to physicans and their extenders, the following: >Participation on Board or Management Committees >Soliciting their input through annual surveys >Offering then "complaint and suggestion" boxes >Having them vet the clinical evidenced-based medical protocols >Recognizing those that performance in an excellent and outstanding manner through appropriate reward programs 3. Support some principles embedded in the Reform Law because "it is the right thing to do! Four such principles include: >Value-based Purchasing Programs >Readmission Reductions >Shared Data with IM Financial support >Support Comparative Effectiveness Research 4. Enhance our Teaming Skills. We certainly have recognized that effective teams has always been critical for success in healthcare. But today, the committment to having a highly effective team and learning how to create and sustain such, must be taken to an even higher level of implementation. The "I" word today has little or no value since the complexities in heathcare must be addressed with sucessful tactics and strategies which can only be formatted by the best of mutliple minds working in an integrated fashion supported by the belief that 1 plus 1 must equal 11 to be truly successful in today's enviorment. In prior blogs......while the CEO of CHRISTUS Health......I wrote about how to create successful teams. These reflections can be found by accessing "Wiresidechates with Dr. Tom" directly. 5. See ourselves as partners with each other, rather than competitors or customers. It is very obvious that many of the failures in healthcare have been driven by a competitive model. Most hospital systems have decided to have everything their competitors all ready are offering, even if the data indicated there is no need for these additional services in the community they are both serving. This duplication of efforts have increased the costs of healthcare significantly, creating at times an unaffordable product that multiplied the number of people who can not access the services. This is the viscious circle, the cost and access curve, that must be broken, and then fixed. Why are we surprised? 6. Building and growing the US healthcare Brand. This must be done by creating a product that has consistyency of performance that is clearly visible to all that use it and can be substaniated by publishable metrics. All successful industries know that brand identity has integrity because when ever you encourter it, wherever you encounter it, and however you encounter it, it has the same benefits, values, and experiences. This integrity is clearly lacking in many of our programs and services from one day to the next. Although these six steps and initiatives seem clear and make sense, why is it that we will have difficulty implementing them? What will be the major constraints preventing us from reaching the top of the "excellence mountain"? The constraints are five in numbers, and will seem all too familar as we debriefed on our previous failures and identified what caused us not to be as successful as we hoped. These include: >Complacency with the staus quo >Vision constains...we can not see the future we must create >Resource contraints...we can not become the low cost provider so our lower margins still give us capital for operational and strategic investments >Teaming and consistency contraints...as I articulated above >Lack of energy to change....we must never think it is easy, but always possible So the question we each must anwer......can we lead our people to overcome these constraints. Nest week, I will put forth the two questions which must be answered by each and everyone of us if tommow we will be successful in addressing the challenges of today.