The Holy Grail in Health Care

High quality, low cost, instant access, online quick fixes, new technology, the costs associated with all of that and hospital food were topics on the table at a CEO Health Care Roundtable discussion in early February. Key Columbia stakeholders were present — Boone Hospital, MU Health Care and Harry S Truman Veterans’ Hospital, among others — and they brought many of the same challenges and opportunities with them.

Sponsored by Peak Sport and Spine and the Broadway Hotel, the luncheon prepared by Broadway Hotel’s Food and Beverage Director and Executive Chef Jeff Guinn featured dishes inspired by “hospital food.” Typical menu items like apple sauce, pot roast, mashed potatoes and banana pudding were transformed into a salad featuring bacon cinnamon apples, candied walnuts, honey dijon and baby spinach; braised short ribs with yukon gold potato puree, pan sauce and baby carrots and asparagus; and finally, a phyllo-wrapped brownie with brûléed banana and roasted peanut caramel.

Inside Columbia Publisher Fred Parry kicked off the conversation, asking for opinions on the health of the Columbia and Boone County health care industry given the amount of transition and change in recent years.

University of Mo. Health Care has been growing very quickly the past several years. While it’s a good challege to face, growth presents a significant obstance for the hospital, to the point where the institution is putting together operational plans for it in its inpatient and procedural settings, says Jonathan Curtright, interim chief executive officer at University of Missouri Health Care.

“It is a stressor, to be real honest,” he says. “It’s a good problem to have, but we anticipate with normal turnover of nursing and our anticipated growth, that we’re going to have to hire probably 600 to 800 nurses in the next three to five years.” In addition to nursing shortages, challenges with facilities associated with growth, as well as with physicians and allied health staff, are also manifesting.

“But it’s a good time of growth,” Curtright adds, “and we’re seeing more and more patients coming from our 25-county catchment area around Columbia that are trying to come to Columbia for destination medical services.

“Growth is our friend; there’s no doubt about it. Certainly, at some point in the future, we’re going to be having more and different revenue models that are out there, but as it stands right now, the large majority of frankly all of health care in the United States is still some sort of fee-for-service medicine … because of that, growth is absolutely your friend.”

Boone Hospital Center is also seeing growth, on the outpatient side in particular, according to Boone Hospital President Jim Sinek.

“There’s a lot of transformation going on in health care across the country, but it’s also happening here in Columbia,” Sinek says. “We happen to be in a geographic region where we’re in bundled payment programs already with hips, knees, ankles and entering into the same kind of bundle payments for cardiology and cardiac surgery. So we’re just moving in a direction where we have to provide care differently than we’ve ever done it before.”

Through bundled payments, insurance companies pay providers and/or health care facilities a single payment for all services relating to a specific episode of care. Those episodes may last up to 90 days or more.

In the future, from a quality of care and reimbursement perspective, fewer inpatients will be more desirable, Sinek adds. “Post-acute providers are going to be significant relative to how we manage not only the quality side but the finance side so we can all be successful.” More integration with independent providers must happen, whether through an employment model, professional services agreements or contractual relationships. It’s started already.

Health care today is different than it was two years ago, and it’s going to be significantly different two years from now, Sinek says. “Organizations that haven’t begun developing the infrastructure, the databases, the computer systems and the relationships that you need are going to have a challenging time.”

Much of the growth at the University of Missouri Hospital and Clinics and at Boone Hospital is a result of decreasing volumes at smaller area hospitals in the region, according to Sinek. Care providers in the mid-Missouri region must plan, with rural providers, on how to provide care and how to coordinate patients getting to the right location at the right time for the best care. “We’re working with our affiliated hospitals and we’re working with the hospital association trying to help support not just Columbia and the urban areas but the rural areas as well.”

Dr. Lana Zerrer, chief of staff at the Harry S Truman Veterans’ Hospital (VA) in Columbia, faces the same growth challenges but with different operational and geographical challenges. In the last 12 years, she has seen the VA go from providing care for 28,000 veterans to caring for 40,000. The VA’s regional coverage extends from north of Kirksville to as far south as Marshfield in coverage of mid-Missouri.

“We are completely landlocked by the university,” Zerrer says. “We keep trying to go up, but construction projects, for us, take a long time to get approved by Congress, and we’re limited by funding levels, etc.

“But we’re facing some of the same challenges that everyone is,” she continues. “The nursing shortage is really hitting us hard … but we also are struggling with some primary care recruitment out in our community-based clinics, which we have eight of those throughout the state.”

Technology advances are slow, Zerrer adds, because of the approval process the VA must go through for funding. “We can’t just say we’re going to start something and then do it. We have to get approval from on high.”

But Zerrer puts another challenge on the table: instant access.

“The biggest thing that I see is that patients now want instant access,” she says, “and if they don’t get it, they complain. Usually when they complain about the VA, it’s on CNN or somewhere like that. A lot of us are under the microscope for access, but that’s our number one priority right now.”

At the Columbia Orthopaedic Group (COG), Dr. Mark Adams, group president and an orthopaedic surgeon, sees growth coming at a challenging time.
“That challenge is on several fronts,” Adams says. “All the major insurers and patients, they want value medicine today. In the last several months, COG has been doing total joint replacements as outpatient, but it’s late to the game. In many markets, that has been the norm for a couple of years.

“That value proposition is especially tough because we have such wonderful technology at our hands now, and that technology doesn’t come cheap,” Adams says. “In this market, we’re in such a premier medical market. We want the best of the new technologies, and yet that comes at a point in time where it’s hard to sometimes justify the cost of these technologies with what the remunerations are today. So on our side, the biggest shift and the things that we think about the most are trying to provide top notch, high-quality medicine in a value setting.”

Dr. Karen Edison, chair of the University of Missouri Department of Dermatology, medical director of the Missouri Telehealth Network and director of the Center for Health Policy, brings the conversation back to access.

“In dermatology, we are completely overrun with patients and have been for quite a long time now,” Edison says. “We could add 10 people and still not meet the access metrics.” Technology also plays heavily into the field’s strategy to meet the demand, but it also brings a unique quality and timeliness challenge.

“We’ve done tele-dermatology in rural underserved parts of Missouri for over 20 years,” she says, “but what we’re seeing in our field is this explosion of direct-to-consumer or direct-to-patient online care.” To gauge the quality of that care, she helped conduct a secret survey using medical students to query 30 online tele-dermatology offerings. The quality issues were quite concerning, she says. Since most Americans have multiple conditions and/or medications, a simple video or photo and a little information is not enough to provide proper care for a patient.

“We’re just in the wild, wild West when it comes to direct-to-consumer care,” Edison says. “Your standard of care does not change just because you’ve got their $59. It’s not time to make your best guess at what’s wrong with them. So in my field, because it’s a visual field, that’s been a real challenge for us.”

In addition, venture capital has gotten behind the direct-to-consumer market, Edison points out. “All of the direct-to-consumer companies are working with big business; they’re working with insurers. They’re working increasingly with health systems, but we still need to keep in mind that health care’s best if it’s regional, if not local. So we’re working to see how we can use this technology to deliver that care in a high quality way.”

Dean of the MU School of Medicine and an interventional cardiologist, Dr. Patrice Delafontaine, also recognizes this is a time of real change in health care.
“We’ve heard about the movement toward different payment models. We haven’t spoken a lot about the innovation that is coming with that,” Delafontaine says.

Taking cost issues into account and a perceived plateau in health care spending, if you look at that equation, there’s going to be increasing emphasis on the cost component of innovation.

“Of course, we all want value and we all want the best for our patients,” Delafontaine says. “The cost is going to become probably more and more important as we go forward.” The university can help develop innovation applicable to health care, from new drugs to devices to clinical decision support systems to clinical infomatics. That’s part of the equation too.

The MU Health Care system is hiring, and it is also training new physicians. National trends indicate a shortage of physicians in the future, if not already on the cusp now and predicted to get worse with the aging population, according to Delafontaine. Strategies to train more physicians are important but need to be done within reasonable costs on that front as well, given it’s well over $250,000 now on average that a medical student owes upon graduation.

But for MU, budget challenges are in the mix with the release of Gov. Eric Greitens’ 2018 budget.

Though costs are a factor, Kristofer Hagglund, dean of MU’s School of Health Professions, says growth is a good descriptor of where his school is at right now. With nine different accredited professional graduate programs and two more coming on board soon, they are seeing 100 percent job placement for professional program students. In the undergraduate program, students that finish without a professional degree still have success in getting jobs. Cerner and MU are the largest employers of graduates, currently.

The School of Health Professions has quintupled the size of enrollment over the past 10 years, according to Hagglund. “It’s a success story right now.”

While growth is consistent across mid-Missouri institutions, so is the nursing shortage, and answers are complicated.

From an education perspective, “It’s really quite difficult to expand the size of programs,” Hagglund says. “There’s only so many clinical training sites available, and of course, nursing, like ours, needs these sites. To start new nursing programs or new nursing schools is expensive. This is not a good time in the economy, especially in education, to start those kinds of programs, and we’re in for a bit of a rough ride for the next 10 years perhaps.”

Parry references Curtright’s aforementioned need of 600-800 new nursing hires in the next three to five years, but Curtright is hopeful.

“We’re blessed with an incredible educational community in central Missouri,” Curtright says. “Certainly, the University of Missouri’s Sinclair School of Nursing produces several hundred outstanding nurses every single year, but on top of all of that we have to think of new ways to train nurses and innovate in non-traditional nurses as well.” Accelerated, online and later-in-life professional development are options. “To this end, we work very closely with our colleagues at Central Methodist University and Columbia College. These schools are excellent and are partners in traning health care professionals,” Curtright says.

In meeting nursing needs, evaluating the level of nursing expertise for specific assignments should also be a constant question, he says. Can the same care being given by an RN be executed by an LPN with support?

At Boone Hospital, it’s a combination of things, Sinek says. Scheduling and staffing innovation is key to addressing any current shortages.

“New nurses, new physicians, like many of the younger generation, have different expectations,” Sinek says. “At Boone we’ve been really changing the way that nursing practice happens. It’s important to be a leader in addressing the nursing shortage.  It’s one of those factors that’s pressuring the cost to go up.”

Competition also affects salary costs when multiple health care institutions compete for nurses from the same candidate pool. “What one does, the next one does plus 5 percent more. Then the next one does 10 percent more,” Sinek says. “We’re kind of spiraling that cost to a certain extent beyond the shortage.” Other innovative options for Boone include a BJC partnership in St. Louis to help produce more PhD nurses so there are more nursing school instructors to meet education and enrollment demands, though this is a longer term option.

At Peak Sport and Spine, Phillip Smith, a physical therapist and outpatient CEO, says it all comes down to quality and cost in regards to bundled payments.
“It’s pretty much about the post-acute program,” Smith says. “It’s about the second the surgery gets over, managing costs and getting the patient into the highest quality and lowest cost care center. There’s a move to transfer patients into the outpatient clinics faster. Moving patients into outpatient settings should decrease the demand on higher cost centers like long-term acute care hospitals, skilled nursing facilities and home health agencies.

“When bundled payments make it to Central Missouri, it’ll be a great opportunity for us,” he adds. “Peak Sport and Spine has been working on a transition system within its existing relationships with the University Hospital, Boone Hospital and Columbia Orthopedic Group. The management of these post-acute programs is in high demand. We’re set up well to move patients throughout the continuum of care.”

“My associations with skilled facilities across the region has helped me foster hundreds of relationships between nurses and therapists that help us progress the patient towards higher functioning and lower cost outpatient settings,” Smith says. “We’ve expanded relationships with multiple home health agencies including Orthopedic and Medical Home Health (OHH), which was set up specifically to help manage bundles for arthoplasty recipients. OHH uses some of the same outpatient therapists to see the patient in the home that will see them when they’ve been discharged to an outpatient center.”

“We’ve set everything up to move one direction, moving into the lower cost settings as quickly as you can get them,” Smith adds. “It’s all about communication and high quality care. We’ve been building this since the Affordable Care Act was voted in and the talks of Comprehensive Joint Replacement programs came out.  We’re so far ahead  because we’re involved in each aspect of the post acute care.  I’m a believer that we will set new standards nationally that others states will follow.”

As a result, the nature of bundled payments influences a provider’s compensation.

“Bundled payment really is just a buzz word for shifting of risk,” Adams says. Insurance companies used to fill the role of risk provider, but now those companies are grouping providers and services for an episode of care. This system has created a wealth of data for physicians and health care systems. That data is critical to determining the price of a low-cost, high-quality bundled payment. Early adaptation of bundled payments on the coasts got some providers into trouble.

However, bundled payments are an opportunity to provide that value medicine that everybody wants, Adams says, but you have to be smart. Eliminate the fluff for the patient and the system, for your physicians to provide that quality care. “The premier word is still ‘quality.’ ”

The bundling experience will look much the same for cardiology, very careful consideration of transition care, according to Delafontaine. Because it will increase consideration in what is used in the cath lab, what stents are implanted, how many wires are used, “ultimately, that will be good because it’ll help us drive waste out of the system,” he says.

A seamless transition with efficient communication of all aspects of patient care is another critical part of the bundled model, says Vickie Pence MS,PA-C of Acute Consulting PLLC. Strong managed health care organizations have been using bundled payments for many years.

“When patients and families are in the hospital, we met with insurance medical directors every day as a team delivering quality treatment plans, which was then communicated on many levels ultimately providing a seamless discharge and plan after the hospitalization,” Pence says. “The patients were transitioned out of the hospital, right into their primary care, and with follow up visits right into a specialty clinic within a few days of discharge.  I think communication is very important and one of the reasons that we are able to propose this program in Columbia educating the medical systems how to improve functionality with our patients care in the systems.”

Partnerships are important to Zerrer, as well, like the ones the VA has developed with Peak Sport and Spine and other home health care agencies. They help keep costs down. Of course, having a patient in one system is easiest, she says, and the VA’s been in a bundled payment system for a long time. So it’s better to keep the number of mediations, procedures and hospital stays down, but leveraging partnerships helps when external options are needed.

Curtright agrees. “The organizations that figure out that entire complex episode of care and figure out how a patient’s flow — from outpatient to inpatient post acute care back to their referring physician, back to their home — they’re the organizations that are going to be successful in this new health care paradigm.”

Bringing all of the pieces together is the challenge, says Dr. Robin Blount, chief medical officer at Boone Hospital.

“One of the major transitions we’re seeing in health care now is the move from the family doctor, who does everything, to the hospital medicine as a specialty,” Blount says. For primary care, gone are the days of efficiently attending patients at the hospital and patients in clinic. The external pressures from payers, government and private, for more efficient care, documentation of quality, length of stay and other expectations, have led to the gradual separation of hospital medicine and outpatient medicine by primary care.

“That’s a huge transition in primary care,” she says. “Then you have to link the health care between the primary doc, what happens in the hospital, you have to link it with EMR (electronic medical records) and good communication. When the patient is discharged, the hospital physician needs to assure that the primary care physician has all the information, knows what took place and can pick up the patient’s care.”

In addition, physicians come out of medical school now with totally different expectations, Blount says. “In working with those expectations, like different hours, we’re not completely there. If it were a bigger organization, a Kaiser, it’s more seamless, but mid-Missouri is still working on that. Bundled payments are our first real challenge to managing episodes of care that extend far beyond those few days in the hospital.”

Bringing more collaboration between hospitals is another perceived community desire, Parry says.

“Columbia has a unique opportunity because even in the private community, many of us went to the University of Missouri and there’s a natural affinity for this community and what this community has been,” Adams says. “Fourteen of my partners have ties to University of Missouri medical school through residency or such. I think you have to pick your way through it; there’s opportunities of low-hanging fruit in some fields. In others, it’s kind of high-hanging fruit, but I don’t think we’re any different than any other industry that’s going through a paradigm shift. The automotive industry went through an unbelievable shift 25 years ago; we’re just late to the game. Who won in that environment? Not the ones who were the stodgy, old, big industries that didn’t pay attention to quality or didn’t pay attention to their employees.

“Our paradigm is changing. The institutions, the physicians, the nurses, everybody is going to have to be entrepreneurs in their own way and find collaboration in places, find unique opportunities,” Adams adds. “The great thing is there are so many ties in this community that revert back to good training, good situations. This community has a rare opportunity for those entrepreneurs to step forward and do some unique things between the systems, between the physicians and the ancillary and allied health care fields. It’s just going to take some people with the right ideas, the right minds and the right ability to think in a new paradigm to move forward.”

Working through the possibility that Columbia hospitals could work more closely together to share more services, Curtright sees an opportunity to attract more sub-specialists if there’s further collaboration and further alignment. If a talented physician-in-training in St. Louis or Chicago sees that here, he or she might think Columbia would be a great place to work.

“We think that with greater collaboration, the entrepreneurial spirit that Dr. Adams described,” Curtright says, “there’s going to be more choice available and better ways to collaborate.”

“BJC supports our trustees evaluation all options, including the university,” Sinek says. There are legal challenges with the university option in terms of being current competitors; however, “there’s services historically that probably could have and should have been collaborated on that are high community-need services.

“We’ve all done community needs assessment and behavioral health seems to always come out at the top. Childhood obesity comes out at the top as well. Those are opportunities that have been missed between the hospitals and the other care providers in Columbia.  We need to work together because a lot of those services, are not profitable. That’s where you get some leeway, legally, to be able to address community needs together to try to reduce your costs and provide greater care in a more comprehensive fashion.

“Really, the holy grail ought to be: Can we continue to improve quality and patient safety and can we reduce our overall cost structure?” Sinek says. “We talk about tourism or destination medicine and Columbia being a basis for that and you mention reimbursement methodologies like bundled payments; I don’t see a relationship between the two at all unless you can do two things: get your costs way down and get your quality where it ranks higher than your competitors.

“Our product is no different than any other product that you put on the market, and value. If you don’t have great quality, nobody’s going to buy it. If you don’t have competitive pricing, nobody’s going to buy it. So that’s the kind of collective product we’re going to have to develop to be a medical destination.”

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