by Fred Fortin
January 29, 2008 at 4:09 pm · Filed under Policy Makers, Facility design/management, Business of Health, Hospital Administration
David Lawrence, former CEO, and chairman of the boards of Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals, speaking yesterday at the Estes Park Conference in Wailea, Maui asks:
Are incremental assumptions about the future of health care plausible?
This question is especially acute when it comes to planning a hospital which could take anywhere from five to ten years to build. Lawrence lays out a number of a propositions that you would have to assume if you were building a hospital today and believed in incremental change in health care.
- Your margins will hold up
- You will recruit and retain critical manpower
- Your customers will remain indifferent to value
- You will meet changes in demand and volume
- Your legal, regulatory and ethical (public) accountability will not change
- You will use new science and technology effectively
- You will respond effectively to competitor threats and external changes
- You will have no alternatives
He prods his audience will questions as to how likely all of or any of these will occur over the next decade? Not likely he says. Uncertainly requires you plan for multiple futures, not one, build flexibility to respond to several possible future scenarios and create institutional capacity to change and adapt. Few blueprints exists for the possible futures that are now in the making for health care.
by Scott MacStravic
July 27, 2007 at 11:34 am · Filed under Pay-for-Performance, Facility design/management, Business of Health
There have long been serious disconnects between what healthcare providers are willing to promise and deliver, and what patients want to get from their healthcare encounters, episodes and relationships. Providers have tended to focus on “doing the right thing”, i.e. using their best judgment, adhering to evidence-based-medicine guidelines, etc. while avoiding accountability for the clinical outcomes and health/life quality value of their services. Patient satisfaction and loyalty to providers is certainly affected by the process of care, the “patient experience” that physicians and hospitals deliver, but are often much more concerned about the results they get.
On occasions when providers look at results, they often fail to recognize the full range of and variations among patients in results desired. Surgeons at the New York Hospital for Special Surgery, for example, focused on the single outcome of pain reduction when assessing the success of their procedures. Patients, on the other hand, looked for regaining ability to do normal activities of daily life, to resume favorite leisure and sports activities, improve their overall quality of life, not merely pain relief, and the specific outcomes desired varied by individual patient. [“Patients and Doctors Often Differ on What Constitutes Successful Surgery” Strategic Health Care Marketing 20:3 March 2003 p.12]
When patients have been the sole or main source of payment for care, however, providers have often been more sensitive to results. Fertility clinics, for example, have frequently guaranteed results or offered patients some or all of their money back if they failed to become parents. The 20/20 Institute in Denver offers a guarantee for its Lasik surgery: if patients do not achieve at least 20/20 vision in the treated eyes, they get a full refund of their payments. (www.2020institute.com/guarantee.htm)
Even hospitals have, on occasion, guaranteed results to some extent. Shouldice Hospital in Toronto has long guaranteed that if hernia repair patients must return for a repetition of the procedure, the surgeon’s fees will be waived. Hospital charges cannot be waived under Canadian law. Geisinger Clinic recently introduces a “ProvenCareSM” program for its coronary bypass surgery, with a warranty covering all needed care during the 90 days post procedure. [A. Casale, et al. “ProvenCareSM: A Provider Driven Pay for Performance Program for Acute Episodic Cardiac Surgical Care” American Surgical Association 2007 Abstracts (www.americansurgical.info/abstracts/2007/20.cgi)]
What such guarantees and warranties tend to do, in addition to promoting patient confidence in getting the desired results, is to motivate providers to strive for the absolute best processes and outcomes of care they can achieve. It alters the current “perverse” incentives in healthcare payment where providers who deliver worse care get paid more, as patients need more care for complications and repetitions or extensions of care, and payers add to their payment for individual episodes. [W. Lynch & H. Gardner “Getting Paid More for Doing Worse…Only in Healthcare” Health as Human Capital July 23, 2007 (hhcf.blogspot.com)
As Lynch and Gardner pointed out, this practice creates what amounts to pay-for-performance incentives for providers, self-imposed rather than offered by payors. It figures to fit very well with the increasing burden that consumers are bearing as employers shift more costs to employees and insurers sell more health spending account plans. It also figures to serve the providers well as they reduce the long-established disconnect between what consumers want to get out of healthcare, and what providers are willing to promise and deliver.
by Scott MacStravic
July 12, 2007 at 3:21 pm · Filed under Facility design/management, Business of Health, Hospital Administration
The two most common approaches to evaluating EHM interventions, which are becoming increasingly popular among employers in general, and healthcare organizations (HCOs), since they are both employers and providers of EHM services in many cases, are:
- Side-by-side comparisons of employees (plus dependents, retirees, when applicable) who are participating in the EHM intervention compared to those not participating
- Comparisons of participants in a period during which they participated in an EHM intervention, compared to a similar period prior to such participation
While common, neither is, by itself, an adequate approach to discovering both what kinds of changes have occurred with the implementation of an EHM program, and whether or not such changes can logically and credibly be attributed to the program. Unfortunately, when one of these is used alone, or even when both are used, but not completely, the findings of evaluations can either exaggerate or understate EHM results, or give far too much credit to EHM for changes that occur due to other factors.
Side-by-Side Comparisons
While it may seem the most logical thing in the world to do, comparing participants in EHM to non-participants is not enough to detect changes, or to ascribe them to the EHM intervention. This is because people who choose to participate in an EHM program are, by definition, different from those who chose not to participate. They may, for example, be younger, more or less healthy, more heavily female than male, or vice versa, etc.
Whenever there are significant differences between participants and non-participants, side-by-side comparisons may reflect no more than differences between these two groups that have nothing to do with their participation. Moreover, when the comparisons cover the same period for both participants and non-participants, they cannot indicate any change in healthcare costs, absences, productivity, performance or value to the organization – only differences between groups.
Before/After Comparisons
If participants in an EHM intervention turn out to have significantly lower healthcare costs, absences, turnover, error rates, etc. compared to these dimensions before they enrolled, there is at least a demonstrated change. But is that change because of the intervention, or was it due to something(s) entirely unrelated to the intervention, even to employee health at all?
The best way to have even an idea as to causality for the change is to make before/after comparisons for participants, and then look at whether these changes were different from what happened among non-participants. By comparing two different groups, participants vs. non-participants over two different periods, before vs. after the EHM intervention, there should be at least enough information to make a logical decision as to whether any differences and changes were “real”, i.e. related directly to the intervention.
I recently read an analysis of the results of a vendor’s program, unfortunately limited to a focus on changes in healthcare costs, rather than the full array of value that employers can obtain from EHM. It reported on side-by-side differences, and concluded that the EHM investment had saved the employer money, and realized a positive ROI after taking into account the costs of the intervention. It used the results to calculate the “breakeven” level of participation, i.e. how many employees would have to participate in order to at least achieve an ROI of $1:1, a dollar saved for every dollar spent.
It added the step of checking on “self-selection bias”, the chance that participants were inherently different from non-participants in a significant way even before the EHM intervention. This involved merely looking at the healthcare costs of participants before the EHM intervention compared to after. And it was found that participants had significantly higher healthcare costs before the EHM program began, hence there really was a change in such costs.
But the analysis lacked the “rest of the story” – it did not compare the before vs. after healthcare costs of non-participants. It is entirely possible that the before/after costs for non-participants dropped as much as such costs did among participants, perhaps even more. If there was a significant drop in the healthcare costs of non-participants, then clearly there was something at work besides the EHM intervention. If so, then the EHM intervention can hardly be given full credit for any apparent change realized among participants.
The use of a complete set of side-by-side comparisons of both participants and non-participants, for periods both before and after the initiation of an EHM program is essential to even basis validity for evaluations. It is by no means the “gold standard” for rigorous scientific evaluation – random assignment of individuals to participation vs. not, and control against external factors would both be needed to achieve such a standard. But with both side-by-side and before/after comparisons –for both participants and non-participants — there is at least some security in avoiding the two most common and serious hazards in evaluation of results.
