A recent survey of 74 C-suite executives, conducted by Health Affairs, revealed that 93% of hospital executives think that health reform will improve healthcare, and that is a testament to integrated hospital innovation that is already underway. These leaders, whose organizations on average, employed 8,520 workers and saw annual revenues of $1.5 billion, have an optimistic view and this is indicative of the continuing work undertaken by providers to make healthcare more accessible, cost efficient, and quality focused.
The executives in this study cited three strategies as critically important to address in order to reduce costs:
By demonstrating better cost controls and adaptations, our hospital clients have seen margin improvement from 3.5% to 5%.
- Reduce the number of hospitalizations
- Reduce the number of readmissions
- Reduce the number of emergency room visits
For every Emergency Department (ED) visit that is seen in a physician office, there would be a cost savings of $1171 per visit. 62% of the ED visits are URGENT, and not EMERGENT. This number has decreased annually over the last five years, but room still exists to cut costs further. By redirecting even 20% of the ED visits nationally, we could save $4.4B; a step forward that has many hospitals very engaged. Use of the ED for urgent care varies – with a range of 42% to 92% by market. An expanded primary care network, more accessible urgent care and one-on-one patient or prospect engagement are keys to shifting the use of the most expensive outpatient program, while making room for the true emergencies. This is a cost, quality, and access focal point for hospitals to continue their innovation, in addition to benchmarked cost effectiveness and care delivery quality excellence.
VP, Advisory Services
A recent commentary notes the shifting of doctors from self-employment to being employed by a heath system. Fully 60% of pediatricians and family medicine physicians are now employed, with 50% of surgeons employed. The number is expected to rise to nearly 75% over the next several years. What is driving that trend? There are at least three compelling answers: debt level, work-life balance, and the hospital’s need to develop market share and control referral patterns.
A recent report states the average medical school student graduates with a debt of nearly $280,000. In 1978, the average debt was $13,000. The student may also have debt obligations from college. Newly trained physicians with that staggering level of debt often don’t want to incur more debt by starting a private practice. The average annual salary of a family medicine provider is $224,000, but for newly trained physicians in private practice, initial revenues are much lower, and it may take several years to get to the average level. Add a home and car mortgage, as well as other personal expenses, and it becomes clear why it’s becoming impossible to absorb the start up costs of a medical practice, which often run as high as $100,000 for a solo practice. By working for a hospital or health system, physicians can avoid all the office costs and the professional liability insurance, while knowing they have a guaranteed salary.
I believe a strong second reason physicians are choosing employment rather than independent practice relates to the difference in lifestyle and work life balance. Most newly trained physicians were born after 1980, and the prospect of managing an outpatient practice and hospitalized patients 24/7 is just not appealing for many of these younger physicians. Working as an employee in a healthcare system that provides a guaranteed salary, utilizes hospitalists, and covers all practice-related expenses is too compelling to turn down. Young physicians also find having personal time off from work very important.
A third reason is the changing market itself. As the country moves away from a fee-for-service payment model to a value-based system, hospitals are moving into risk contracting or capitated payments. The best strategy for hospitals and health systems is to exert more control over the markets in which they serve. By employing physicians, hospitals can transfer office-based services into their own outpatient labs and radiology suites. Hospitals with employed physicians can more effectively direct patient admission choices. As Accountable Care Organizations (ACOs) mature, they will assume financial responsibility across the entire care continuum, from outpatient services to admissions, rehabilitation and long-term care. ACOs will drive the need for more efficient care with less wasteful spending. Hospitals can drive that efficiency with smart IT investments, treatment guidelines and care coordination. This can be done without employing physicians, but it’s more efficient to employ physicians and have them be a part of the process. To fully support care, a newer trend is for hospitals to employ specialists in addition to primary care physicians.
One potential advantage of employing physicians is the opportunity to reduce the variation in medical care that is rampant in the U.S. today. Reducing variation should improve the quality of care and reduce costs by avoiding wasteful and unneeded treatments that may be costing the U.S. up to 30% of the total medical spend. Aligning physicians and hospitals to the triple aim – better care for individuals, better care for the population, and slowing medical inflation is best accomplished in an organized approach – and individually owned practices are less likely to deliver on that promise.
Michael L. Taylor, MD, FACP
Chief Medical Officer
I read about the new bipartisan bill for the “doc-fix” with great anticipation. This bill is a solution to the sustainable growth rate (SGR) problem. The idea of the SGR was to put a limit on annual payment increases for physician services for Medicare patients. The SGR is generally acknowledged to be flawed, because it places arbitrary caps on spending without properly accounting for increases in the volume of services. Centers for Medicare and Medicaid Services (CMS) has experienced payment overruns in every year since it was enacted, and Congress, rather than enforcing the provisions of the bill, made a temporary adjustment, thereby worsening the overrun for the next year. By 2014, to maintain the SGR, CMS would need to decrease physician payments by 24 percent!
The new bill addresses this problem by replacing the SGR; instead, physicians will now see a 0.5 percent increase in payment annually for the next five years. It also incentivizes quality improvement in medical care by encouraging development of alternative payment models. Physicians may receive a 5% “bonus” payment, if at least 25% of their revenue is derived from a patient centered medical home arrangement by 2018. CMS is attempting to change from a fee-for-service payment model (the more services a physician provides, the higher the payment) to a model based on quality outcomes.
I applaud this effort, but there is significant work to be done in switching from a volume-based payment model to a quality-of-outcome model. The most basic (and difficult) challenge is defining which quality metrics to incentivize. The plan is to use the Physician Quality Reporting System or PQRS, (CMS loves acronyms!). As I reviewed the more than 300 quality metrics, it struck me that most measures were process measures, such as:
These are good metrics, but do they actually reflect the quality of care delivered? Physicians have long resisted being measured on quality, because they don’t trust the data. They generally feel the metrics represent just a small part of their practices and many of the metrics focus on primary care. There is less focus on specialty and surgical care metrics, and these areas comprise the bulk of the medical spend. Metrics that look at the patient experience, such as how well the patient fared, are available, but minimally represented in the PQRS metrics. Important outcome measures need to be included, such as what percent of those with diabetes achieved all recommended BP, LDL cholesterol, and A1c goals, not just what percent received recommended care.
- Testing appropriately or prescribing certain medications when treating diabetes patients
- Giving aspirin to heart attack patients in a timely manner
- Offering the right treatment advice for back pain
Metrics are necessarily patient-based, but as new deliver models emerge, new metrics need to be utilized. The Affordable Care Act incentivizes health systems to focus on treating entire populations, not individuals, and helps pay for the IT infrastructure needed to manage and measure the health of a population. We need to use metrics focused on entire populations, not just on patients who happen to see their doctors.
Physicians will accept the metrics, if they have a role in determining, by specialty, which metrics best reflect high-quality care, and which metrics reflect appropriate care. This means measuring wasteful treatments and procedures.
I am a strong advocate of eliminating fee-for-service medicine. In my opinion, this payment model is a root cause for many of the problems in U.S. healthcare delivery. I applaud the effort to incentivize and measure value in health care, not volume. Developing and implementing a strong and accurate system of quality measures will be a giant step in the right direction.
Michael L. Taylor, MD, FACP
Chief Medical Officer
Tina Rosenberg, a highly respected healthcare journalist for the New York Times, recently published a two-part “Opinionator” series on healthcare costs. The second article in the series discussed the Truven Health white paper from 2012 that describes the $36 billion savings opportunity due to price variation among providers. I was pleased to speak with Ms. Rosenberg about the topic, and provide background information for the article.
Our research (and others) has shown price variation based on geographic location, with some areas of the country charging much higher rates than others for similar services—and not demonstrating any significant improvement in quality or outcomes. Our white paper extends the research to show prices also vary within any given market, again without discernible differences in quality. As an example, a hospital charge for a similar procedure may vary by a two-fold difference, based on the discounts negotiated between the payer and the hospital.
Further, the Institute of Medicine (IOM) recently reported even more information on price variation and pointed out the value of price transparency. That paper argues that it would be a mistake for CMS to make significant pricing changes based on geographic principles alone. One of the major data sources? The Truven Health MarketScan® Research Databases, and one of the consultants working with IOM on this paper was our own Teresa Gibson, PhD.
This topic of price transparency helps understand how to improve the quality and decrease the price of healthcare—the stated vision of Truven Health Analytics. This is a tangible example of how we are fulfilling that vision.
Michael L. Taylor, MD FACP
Chief Medical Officer
In the July 2, 2013 edition, HealthLeaders Media stated "Healthcare Quality Metrics ‘Abysmal,’ Senate Panel Hears," and this article clearly highlighted the palpable frustration voiced by providers, payers and patients. How do we characterize hospital outcomes that would be meaningful to all three groups and most importantly drive best practices?
If the hospital CEO pronounced that we expect all care in the hospital to be the “best,” it would likely be met with applause and a shrug of the shoulders. Who would argue against such a goal? Yet, how do I, listening to that call to action, effectively contribute to this vision?
Of course, it begins with meaningful, actionable data that effectively captures the essence of both gaps in current performance and strengths upon which to leverage future efforts. Recognizing that leadership often views success from 30,000 feet; change is accomplished one project at a time and by ensuring all stakeholders trust the data and believe he or she can impact the diagnosis or procedure in question.
No doubt the public confusion over healthcare information will persist in the short term. Competing safety measures, migration from process to outcomes metrics, and multiple means to “rate” care have lead to a spectrum of responses; from frenetic reflexive behavior to fearful cautious retreat. It is our call to action to ensure that data is more than just numbers; that it provides clarity to those delivering best practice and accurately reflects the standards of excellence we all expect as patients!
Michael R. Udwin, MD, FACOG
National Medical Director