DIVURGENT

By David Shiple, Practice Leader, Advisory Services

The tea leaves are beginning to clearly point to a not-too-distant-future of downsizing and consolidation among acute care facilities.  ACOs, PCMHs, and other reforms are correctly aimed at keeping patients out of expensive acute care settings whenever possible.  Much effort, planning, and spending is going into the creation of the infrastructure (HIEs, data aggregation, analytics, etc.) needed to support these new payment models.  The capital investments are partly funded through HITECH (although, not for much longer), and by our health systems.  And, within the health system umbrella, the hospitals are the center of gravity for the capital, implementation resources, and experience needed to make the needed infrastructure a reality.

So, the side of the health care delivery system that provides much of the expensive (and often times unnecessary) care, is the side that can put the infrastructure in place to enable new payment models and reverse the upward spiral of healthcare costs.  Sounds like a plan.

There could be a painful rub, though – and, it’s about timing.   It could be that just when health system capital investments are at their peak – with the needed infrastructure half completed – is the time that health systems are feeling the big financial pinch of healthcare reform.  A big, continually building pinch, that is.  And not just today’s reform legislation, but my bet is on the many unfunded mandates to follow.  After all, the curve to be bent down is a big one.  And part of area under that smaller curve is heath system capital availability.

So the irony is that the nation’s hospitals will be building the infrastructure that will put them (at least partially) out of business.

But wait.  The health systems will offset this by buying primary care practices, right?  Maybe – but it will take a lot of primary care revenue to equal the revenue of one of ICU bed (which is not a bad thing – we want to keep people out of the ICU).  Or, maybe the demographics of the baby-boomer generation will increase overall patient volume and offset this calamitous trend?  Maybe a little, but I’m not sure if this changes my premise – I believe we’re going to get better and better at keeping people healthy and out of the health system.

So it’s back to the capital question.  A question that Divurgent professionals have given a lot of thought to and one for which we have some answers.

by Jeff Goldstein, Divurgent

The June Federal Advisory Committee (FACA) meeting on Healthcare IT published the minutes of their meeting this week along with its recommendations for revising Meaningful Use (MU) Stage 3.  While Stage 2 has yet to be finalized, the scope and content of these recommendations clearly points to a subtle, yet important change in the long-term direction of MU. We would like to focus on two areas we feel will have significant impact on having Meaningful Use continue to improve healthcare.

These recommendations are focusing on patient safety and care efficiency at a global level, and they should be viewed as a positive step in improving our healthcare system.  Included in the revisions of Stage 3 would be recognition that healthcare delivery is a continuum, and coordination across all providers at all levels is a cornerstone of effective healthcare.  If these Stage 3 recommendations were to be implemented, then coordination of care would begin in the acute care setting, but electronic integration to sub-acute and/or long term care providers would be a necessary component.  This also recognizes that long term care (LTC) is now providing services previously available only in the acute care setting with the proof being the steady decline in acute care beds while LTC bed capacity continues to grow.

The problem is that LTC is far from ready to integrate with hospital EMRs.  We also have to recognize that unlike an acute care hospital, the phrase “LTC” reflects a variety of facilities that includes Long Term Acute Care (LTAC), Skilled Nursing (SNF), Home Care (HC) and Assisted Living (AL).  Presently, no significant federal funding programs exist to help these facilities implement EMR systems, and even if there were, vendors have been slow to develop LTC EMR systems that reflect the nomenclature, billing, and the scope of care delivery systems found in LTC.

The LTC EMR problem is made even more difficult in that physicians frequently coordinate care but not necessarily while at the facility. This would then require there be some sort of information exchange backbone that brings all the components together independent of where they are.  Health Information Exchanges (HIEs) are becoming more prevalent and the market does have a number of excellent mobile solutions for gathering data, but the technology needed to shunt bidirectional information to and from the provider and to the appropriate EMR (hospital, LTC, office) is still in its infancy.  If we include other providers such as physical therapy, home infusion and other services that are now solidly integrated into LTC, then the amount of work needed to be done and the money to do it with may very well dwarf what has been needed to implement hospital EMRs.

Quality was also foremost on the FACA agenda.  Quality is intimately tied to clinical decision support (CDS) and there is a high level of consensus that this must be driven through standardized data gathered from the EMR.  In order for this to work, however, a number of elements must be in place for this to work.

Hospitals and providers need to have a standardized clinical content reference tool that is seamlessly integrated into the EMR.  This content needs to be coupled with the use of standardized order sets that are structured on evidence-based medicine recommendations but also allows the incorporation of proven best practices for the organization.  The recommendations look to the EMRs to provide this, but    while EMR vendors have suggested that they either have the tools already in their products or that it will be available soon, the market has not been satisfied with what they have seen.  These organizations then look to purchase proven CDS workflow and surveillance tools from third party vendors.  We should not expect this trend to vary. Rather, EMRs should look to facilitate integration with these tools, or the Stage 3 recommendations for quality measurement cannot be achieved.

It was announced that the Committee would begin public comments in November; however with the elections at the same time, it is doubtful that no matter which party gets the keys to the White House in January, any final revisions to Stage 3 would not be presented until well into 2013.  Nevertheless, the ensemble of the proposed revisions do make sense for improving quality, increasing the efficiency of care, and keeping healthcare costs from bankrupting the country.  The problem is that the planners have to look at the totality of their recommendations, and now is the time to identify all the components and interactions these recommendations have and to determine the cost, time, and systems needed properly implement them

By:  Jeff Goldstein, Divurgent

The Supreme Court has released its decision on the Healthcare Reform Act, and while there will be much debate through November and well beyond as the various programs within the law are enacted, one thing is clear. While we claim to have the best healthcare in the world, the fact is that as a nation, some have the best healthcare money can buy, but for others, our present system can be considered mediocre at best.

This harsh reality is supported by many international studies and reports. According to the WHO 2010 study on healthcare quality, the US is ranked 37^th amongst nations with France ranked as number 1 and the US listed between Costa Rica (36^th place) and Slovenia (38^th place).  However, when we look at healthcare costs, what matters perhaps even more is the fact that we are simply not getting good value for our money.  Japan, ranked 10^th in healthcare quality on the 2010 WHO survey, spends 8.1% of their GDP on healthcare, whereas the US spends 15.3%. However, a better barometer for the quality of healthcare would be to look at outcomes.  Again, Japan is the winner with infant mortality at 3 per 1,000 and the average life expectancy is 83 years. In contrast, infant mortality in the US is 7 per 1000 (more than double) and the average life expectancy for an American is 78 years.

Let’s not, however, be naïve and assume that the Supreme Court decision will have any impact on the immediate future on how well our healthcare system performs.    What it will do, however, is allow the process of improving our care to begin and hold us accountable as a society for the overall well-being of our nation. What we should also expect to see is that over time, components within the law will evolve, and we will look to modify them to take on the best elements of other proven systems that best match our needs.  For example, the Netherlands mandates that all their citizens have health insurance, but the Dutch have to obtain coverage through private insurers.  These providers can be either for-profit or not, but in any case, the government has strictly defined operating standards that all insurers must follow, and perhaps the most important fact is that coverage cannot be denied for pre-existing conditions. Enrollees can opt for different levels of coverage, and government subsidized tax credits are available for low-income individuals and families. This can be one approach that would find support on both sides of the Congressional aisle.

While we should expect that the debate in Washington will continue, we cannot ignore that over 16% of Americans are without healthcare coverage. An even more alarming number to consider is the subset of Americans who are working but without insurance. In Texas, for example, it is estimated that 70% of the uninsured population are, in fact, employed but their employers are not providing coverage. Because they are without insurance, they are not involved in preventive or ongoing care. Instead, when they require medical attention, they use the hospital emergency room as their de facto primary care provider. The problem is further compounded when follow up is lacking and cost-effective ongoing primary care is replaced by repeat visits to emergency services. Multiply this to reflect the entire nation and the inappropriate use of services is simply unacceptable.

The Supreme Court decision is a major first step in addressing this problem.   Now is the time to put the political debates aside and move ahead on implementing programs that address high-quality and cost effective healthcare for all Americans.  Let us not forget it has been nearly 50 years since Medicare was introduced to address the fact that over half of Americans over the age of 65 did not have healthcare coverage.  As a society, we need to recognize that healthcare is a right rather than a privilege, but it does come at a cost. The intent of the bill is to share this cost across society so that every American rather than just some can have equal access to the right care at the right time.